Healthcare Provider Details

I. General information

NPI: 1073815791
Provider Name (Legal Business Name): MIKE WALSH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10299 WOODMAN RD
GLEN ALLEN VA
23060-4419
US

IV. Provider business mailing address

5408 CHAMBERLAYNE RD
RICHMOND VA
23227-2407
US

V. Phone/Fax

Practice location:
  • Phone: 804-836-4499
  • Fax: 804-727-8480
Mailing address:
  • Phone: 804-272-2000
  • Fax: 804-272-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701004951
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: