Provider Demographics
NPI:1427268978
Name:WALSH, THOMAS EUGENE
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EUGENE
Last Name:WALSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19816 COUNTY ROAD 8
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-2218
Mailing Address - Country:US
Mailing Address - Phone:132-027-8327
Mailing Address - Fax:
Practice Address - Street 1:222 9TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2221
Practice Address - Country:US
Practice Address - Phone:132-076-3391
Practice Address - Fax:132-076-3662
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNTEMPORARY-ADC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)