Provider Demographics
NPI:1275671919
Name:WALSH, MARY LOUISE (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:WALSH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5984
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-8033
Mailing Address - Country:US
Mailing Address - Phone:909-815-5462
Mailing Address - Fax:951-279-6155
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-7320
Practice Address - Fax:951-955-7203
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40018106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 40018OtherMFT LICENSE