Provider Demographics
NPI:1912151564
Name:WALSH, MICHAEL L (LMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:WALSH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 NE ALBERTA ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5881
Mailing Address - Country:US
Mailing Address - Phone:503-888-8994
Mailing Address - Fax:
Practice Address - Street 1:1829 NE ALBERTA ST STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-5881
Practice Address - Country:US
Practice Address - Phone:503-888-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6240172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist