Provider Demographics
NPI:1568694735
Name:WALZ, MICHELLE LYNN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:WALZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8037 FAIR OAKS BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6742
Mailing Address - Country:US
Mailing Address - Phone:916-542-1308
Mailing Address - Fax:
Practice Address - Street 1:8037 FAIR OAKS BLVD STE 112
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6742
Practice Address - Country:US
Practice Address - Phone:916-542-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98650106H00000X
CA66285106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist