Provider Demographics
NPI:1699750018
Name:WALSH, KIMBERLY RUTH (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:RUTH
Last Name:WALSH
Suffix:
Gender:F
Credentials:PSYD
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 150214
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0214
Mailing Address - Country:US
Mailing Address - Phone:801-690-0353
Mailing Address - Fax:801-479-7020
Practice Address - Street 1:1452 EAST RIDGELINE DRIVE
Practice Address - Street 2:SUITE 151
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-690-0353
Practice Address - Fax:801-479-7020
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117391-2501103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR92071Medicare UPIN