Provider Demographics
NPI:1730578071
Name:WALTERS, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
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 1:9940 ALVATON ROAD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122
Mailing Address - Country:US
Mailing Address - Phone:270-202-7232
Mailing Address - Fax:
Practice Address - Street 1:9940 ALVATON RD
Practice Address - Street 2:
Practice Address - City:ALVATON
Practice Address - State:KY
Practice Address - Zip Code:42122-9657
Practice Address - Country:US
Practice Address - Phone:270-746-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100352540Medicaid