Provider Demographics
NPI:1457452161
Name:WALZ, PATRICIA J (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
Last Name:WALZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S WALDRON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2590
Mailing Address - Country:US
Mailing Address - Phone:479-785-1995
Mailing Address - Fax:479-308-3971
Practice Address - Street 1:1401 S WALDRON RD STE 206
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2590
Practice Address - Country:US
Practice Address - Phone:479-785-1995
Practice Address - Fax:479-308-3971
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR90-18P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118624719Medicaid
AR118624719Medicaid