Healthcare Provider Details

I. General information

NPI: 1164014171
Provider Name (Legal Business Name): IDA L WALSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3272 RIVA RD
RIVA MD
21140-1110
US

IV. Provider business mailing address

PO BOX 146
RIVA MD
21140-0146
US

V. Phone/Fax

Practice location:
  • Phone: 410-956-0346
  • Fax:
Mailing address:
  • Phone: 410-956-0346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAC0656
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC0656
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: