Provider Demographics
NPI:1457723736
Name:WALZ, ELISHEVA (LLMSW)
Entity Type:Individual
Prefix:
First Name:ELISHEVA
Middle Name:
Last Name:WALZ
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 FONTAINE PL
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1441
Mailing Address - Country:US
Mailing Address - Phone:248-885-3727
Mailing Address - Fax:
Practice Address - Street 1:15300 FONTAINE PL
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1441
Practice Address - Country:US
Practice Address - Phone:248-885-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010979961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI120627102Medicaid