Provider Demographics
NPI:1902142227
Name:WALTERS, ASHLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14115 JAMES RD STE 305
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9417
Mailing Address - Country:US
Mailing Address - Phone:763-575-8086
Mailing Address - Fax:
Practice Address - Street 1:14115 JAMES RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9468
Practice Address - Country:US
Practice Address - Phone:637-575-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN267181041C0700X
104100000X
CT87991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker