MEDICARE: MR. MARK S WALSTROM L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6401003116	MI

General Provider Information

NPI Number	:	1780750844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK S WALSTROM L.P.C.

Provider Business Mailing Address
First Line	:	967 SPAULDING AVE SE
Second Line	:	SUITE E
City	:	ADA
State	:	MI
Zip	:	49301-3700
Country	:	US
Telephone Number	:	616-633-2170
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 SPAULDING AVE SE
Second Line	:	SUITE E
City	:	ADA
State	:	MI
Zip	:	49301-3700
Country	:	US
Telephone Number	:	616-633-2170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	01/26/2009

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