Healthcare Provider Details

I. General information

NPI: 1104336569
Provider Name (Legal Business Name): MELINDA SUE WALSH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11126 WAYNE RD STE 5
ROMULUS MI
48174-1473
US

IV. Provider business mailing address

37805 WOODRIDGE DR APT 105
WESTLAND MI
48185-5775
US

V. Phone/Fax

Practice location:
  • Phone: 734-217-7313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115362
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801115362
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: