=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104336569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELINDA SUE WALSH LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2017
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11126 WAYNE RD STE 5
-----------------------------------------------------
City | ROMULUS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48174-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-217-7313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37805 WOODRIDGE DR APT 105
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801115362
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801115362
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------