Provider Demographics
NPI:1427711407
Name:WALZ, IAN MATTHEW (LMHC)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:WALZ
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5114 N CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-3380
Mailing Address - Country:US
Mailing Address - Phone:518-954-9381
Mailing Address - Fax:
Practice Address - Street 1:2155 ROUTE 22B
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3417
Practice Address - Country:US
Practice Address - Phone:518-563-8000
Practice Address - Fax:518-563-9001
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014140101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health