Provider Demographics
NPI:1396756383
Name:WALSH, LORAINE L (PHD)
Entity type:Individual
Prefix:DR
First Name:LORAINE
Middle Name:L
Last Name:WALSH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26932 OSO PARKWAY
Mailing Address - Street 2:#200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691
Mailing Address - Country:US
Mailing Address - Phone:949-367-9797
Mailing Address - Fax:949-348-9626
Practice Address - Street 1:26932 OSO PARKWAY
Practice Address - Street 2:#200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-367-9797
Practice Address - Fax:949-348-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4408103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY04408Medicaid
CP4400Medicare ID - Type Unspecified
CAPSY04408Medicaid