Provider Demographics
NPI:1679651061
Name:WALSH, LISA KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KATHLEEN
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 1:233 FULTON ST E
Mailing Address - Street 2:SUITE 14
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3200
Mailing Address - Country:US
Mailing Address - Phone:616-915-2486
Mailing Address - Fax:616-776-5543
Practice Address - Street 1:233 FULTON ST E
Practice Address - Street 2:SUITE 14
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3200
Practice Address - Country:US
Practice Address - Phone:616-915-2486
Practice Address - Fax:616-776-5543
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008820103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical