Provider Demographics
NPI:1780750844
Name:WALSTROM, MARK S (LPC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:WALSTROM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:967 SPAULDING AVE SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-3700
Mailing Address - Country:US
Mailing Address - Phone:616-633-2170
Mailing Address - Fax:
Practice Address - Street 1:967 SPAULDING AVE SE
Practice Address - Street 2:SUITE E
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-3700
Practice Address - Country:US
Practice Address - Phone:616-633-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401003116101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7909106890Medicare UPIN