Healthcare Provider Details

I. General information

NPI: 1427089036
Provider Name (Legal Business Name): GREGORY DAVID WALSH LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ARBORETUM BLVD SUITE # 211
VICTORIA MN
55386-7705
US

IV. Provider business mailing address

PO BOX 82 VICTORIA MENTAL HEALTH SERVICES, LTD.
VICTORIA MN
55386-0082
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-3970
  • Fax: 952-368-3177
Mailing address:
  • Phone: 952-443-3970
  • Fax: 952-368-3177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9379
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: