Provider Demographics
NPI:1124376702
Name:WALSH, TIMOTHY BRIAN (LP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRIAN
Last Name:WALSH
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7041 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9737
Mailing Address - Country:US
Mailing Address - Phone:651-407-3631
Mailing Address - Fax:651-407-3751
Practice Address - Street 1:7041 20TH AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MN
Practice Address - Zip Code:55038-9737
Practice Address - Country:US
Practice Address - Phone:651-407-3631
Practice Address - Fax:651-407-3751
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist