Provider Demographics
NPI:1578557450
Name:WALSH, BEVERLY DOLENZ (PHD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:DOLENZ
Last Name:WALSH
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 1:14034 HOOPER RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-5212
Mailing Address - Country:US
Mailing Address - Phone:713-540-1528
Mailing Address - Fax:713-433-2339
Practice Address - Street 1:14034 HOOPER RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-5212
Practice Address - Country:US
Practice Address - Phone:713-540-1528
Practice Address - Fax:713-433-2339
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25992103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102550401Medicaid
S40108Medicare UPIN
TX82698PMedicare ID - Type Unspecified