Provider Demographics
NPI:1700763299
Name:WALTERS RODNEY, ROSHELLE WANDERLEE
Entity type:Individual
Prefix:
First Name:ROSHELLE
Middle Name:WANDERLEE
Last Name:WALTERS RODNEY
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 1:2207 PIXIE ROSE LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5104
Mailing Address - Country:US
Mailing Address - Phone:404-200-1609
Mailing Address - Fax:
Practice Address - Street 1:3993 LAWRENCEVILLE HWY NW STE 110
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2831
Practice Address - Country:US
Practice Address - Phone:404-868-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician