Provider Demographics
NPI:1700221991
Name:WALZ, EMILY REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:REBECCA
Last Name:WALZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3718
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:414-672-4265
Practice Address - Street 1:309 E NORTH ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3718
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-672-4265
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64143-202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700221991Medicaid