Healthcare Provider Details

I. General information

NPI: 1760024889
Provider Name (Legal Business Name): CHRISTINA JEAN WALSH MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1844 OAK HOLLOW DR STE B
TRAVERSE CITY MI
49686-5924
US

IV. Provider business mailing address

1129 BARLOW ST
TRAVERSE CITY MI
49686-4254
US

V. Phone/Fax

Practice location:
  • Phone: 231-714-0282
  • Fax:
Mailing address:
  • Phone: 650-745-6345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801105858
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: