Healthcare Provider Details

I. General information

NPI: 1699750018
Provider Name (Legal Business Name): KIMBERLY RUTH WALSH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 EAST RIDGELINE DRIVE SUITE 151
SOUTH OGDEN UT
84405
US

IV. Provider business mailing address

PO BOX 150214
OGDEN UT
84415-0214
US

V. Phone/Fax

Practice location:
  • Phone: 801-690-0353
  • Fax: 801-479-7020
Mailing address:
  • Phone: 801-690-0353
  • Fax: 801-479-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number117391-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number117391-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: