Provider Demographics
NPI:1144490210
Name:WALTERS, MARY ALICE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 HIGHWAY NINETY TWO
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-2234
Mailing Address - Country:US
Mailing Address - Phone:434-738-6566
Mailing Address - Fax:
Practice Address - Street 1:670 HIGHWAY NINETY TWO
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917-2234
Practice Address - Country:US
Practice Address - Phone:434-738-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040026241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical