Provider Demographics
NPI:1407823206
Name:WALSH, SUSAN MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:(FAHEY BLDG., RM. 222)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3750
Mailing Address - Fax:708-216-6840
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(FAHEY BLDG., RM. 222)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3750
Practice Address - Fax:708-216-6840
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL710051682084P0800X
IL071005168103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL71005168Medicaid
IL71005168Medicaid
IL650550Medicare ID - Type Unspecified