Provider Demographics
NPI:1538419841
Name:WALSH, JOHN MICHAEL (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:WALSH
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108D MORADA LN
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6580
Mailing Address - Country:US
Mailing Address - Phone:831-332-3979
Mailing Address - Fax:
Practice Address - Street 1:310 CAMINO DE LA PLACITA
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5951
Practice Address - Country:US
Practice Address - Phone:575-758-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM292863103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool