Healthcare Provider Details

I. General information

NPI: 1740704287
Provider Name (Legal Business Name): MELONY DAWN WALSH MS ED, LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E GRAND AVE
BELOIT WI
53511-6314
US

IV. Provider business mailing address

540 E GRAND AVE
BELOIT WI
53511-6314
US

V. Phone/Fax

Practice location:
  • Phone: 608-368-8087
  • Fax: 608-312-2061
Mailing address:
  • Phone: 608-368-8087
  • Fax: 608-312-2061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: