Provider Demographics
NPI:1760574826
Name:WALSH, DIANNE (LISW)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-271-6300
Mailing Address - Fax:515-271-6311
Practice Address - Street 1:1750 48TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1988
Practice Address - Country:US
Practice Address - Phone:515-271-6300
Practice Address - Fax:515-271-6311
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00704104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11398Medicare ID - Type Unspecified
IAP48941Medicare UPIN