Provider Demographics
NPI:1457425951
Name:EKLUND WALSH, LORI JO (LCSW,LPC,SAC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JO
Last Name:EKLUND WALSH
Suffix:
Gender:F
Credentials:LCSW,LPC,SAC
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 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153
Practice Address - Country:US
Practice Address - Phone:920-835-5500
Practice Address - Fax:920-835-5510
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15877132101YA0400X
WI2960125101YP2500X
WI83551231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43565300Medicaid