Provider Demographics
NPI:1356566483
Name:WALSH, PAUL M (PSYD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:WALSH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SEARS AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5072
Mailing Address - Country:US
Mailing Address - Phone:502-899-1282
Mailing Address - Fax:
Practice Address - Street 1:120 SEARS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5072
Practice Address - Country:US
Practice Address - Phone:502-899-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY853103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3014901OtherMEDICARE