Provider Demographics
NPI:1689821654
Name:WALZ, LAEL A
Entity Type:Individual
Prefix:
First Name:LAEL
Middle Name:A
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 1:714 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6410
Mailing Address - Country:US
Mailing Address - Phone:530-205-7932
Mailing Address - Fax:
Practice Address - Street 1:714 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6410
Practice Address - Country:US
Practice Address - Phone:530-205-7932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor