Healthcare Provider Details

I. General information

NPI: 1538419841
Provider Name (Legal Business Name): JOHN MICHAEL WALSH SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 CAMINO DE LA PLACITA
TAOS NM
87571-5951
US

IV. Provider business mailing address

108D MORADA LN
TAOS NM
87571-6580
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5200
  • Fax:
Mailing address:
  • Phone: 831-332-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number292863
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: