Provider Demographics
NPI:1477890846
Name:WALSH, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S ELISEO DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2134
Mailing Address - Country:US
Mailing Address - Phone:415-461-9247
Mailing Address - Fax:
Practice Address - Street 1:900 S ELISEO DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2134
Practice Address - Country:US
Practice Address - Phone:415-461-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-05
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC30448OtherLICENSE
CAC30448OtherLICENSE