Provider Demographics
NPI:1689732752
Name:WALSH, PATRICK (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:WALSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6078
Mailing Address - Country:US
Mailing Address - Phone:630-909-8608
Mailing Address - Fax:630-909-8603
Practice Address - Street 1:26W171 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-6078
Practice Address - Country:US
Practice Address - Phone:630-909-8608
Practice Address - Fax:630-909-8603
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP05926Medicare UPIN
ILL78142Medicare ID - Type Unspecified
ILL78143Medicare ID - Type Unspecified