Provider Demographics
NPI:1427089036
Name:WALSH, GREGORY DAVID (LICSW)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DAVID
Last Name:WALSH
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:VICTORIA MENTAL HEALTH SERVICES, LTD.
Mailing Address - City:VICTORIA
Mailing Address - State:MN
Mailing Address - Zip Code:55386-0082
Mailing Address - Country:US
Mailing Address - Phone:952-443-3970
Mailing Address - Fax:952-368-3177
Practice Address - Street 1:1600 ARBORETUM BLVD
Practice Address - Street 2:SUITE # 211
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-7705
Practice Address - Country:US
Practice Address - Phone:952-443-3970
Practice Address - Fax:952-368-3177
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN93791041C0700X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
6236362OtherMEDICA-UBH
MN0488739-00Medicaid
MN048873900Medicaid