Provider Demographics
NPI:1275851875
Name:WALTZ, THOMAS JOSEPH (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:WALTZ
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2127
Mailing Address - Country:US
Mailing Address - Phone:734-340-4043
Mailing Address - Fax:
Practice Address - Street 1:715 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2127
Practice Address - Country:US
Practice Address - Phone:734-340-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016487103TC0700X
AR10-28 AE-PL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301016487OtherMICHIGAN PSYCHOLOGY BOARD