Provider Demographics
NPI:1801631502
Name:WALSH, JOHN ANDREW (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:WALSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 EMPIRE STATE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-8201
Mailing Address - Country:US
Mailing Address - Phone:812-878-8880
Mailing Address - Fax:
Practice Address - Street 1:3425 EMPIRE STATE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-8201
Practice Address - Country:US
Practice Address - Phone:812-878-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TE1100X
MI6301019341103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports