Provider Demographics
NPI:1578531315
Name:WALCOTT, DELORES D (PSYD)
Entity Type:Individual
Prefix:MS
First Name:DELORES
Middle Name:D
Last Name:WALCOTT
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 1:3609 CANTERBURY AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006
Mailing Address - Country:US
Mailing Address - Phone:269-373-6436
Mailing Address - Fax:
Practice Address - Street 1:2935 DANFORD CREEK
Practice Address - Street 2:UNIT 4
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009
Practice Address - Country:US
Practice Address - Phone:269-353-4558
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009797103T00000X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON76580Medicare ID - Type UnspecifiedB