Provider Demographics
NPI:1497314918
Name:WALCH, KELLY A (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WALCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 W MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4739
Mailing Address - Country:US
Mailing Address - Phone:215-850-5397
Mailing Address - Fax:
Practice Address - Street 1:209 E BASELINE RD
Practice Address - Street 2:STE E102 #2
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1299
Practice Address - Country:US
Practice Address - Phone:215-850-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-08
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-171161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical