Healthcare Provider Details

I. General information

NPI: 1679651061
Provider Name (Legal Business Name): LISA KATHLEEN WALSH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E SUITE 14
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

233 FULTON ST E SUITE 14
GRAND RAPIDS MI
49503-3200
US

V. Phone/Fax

Practice location:
  • Phone: 616-915-2486
  • Fax: 616-776-5543
Mailing address:
  • Phone: 616-915-2486
  • Fax: 616-776-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301008820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: