Provider Demographics
NPI:1003187477
Name:WALTS, LAURA MARIE (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:WALTS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41641 N RIDGE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1245
Mailing Address - Country:US
Mailing Address - Phone:440-260-6110
Mailing Address - Fax:
Practice Address - Street 1:41641 N RIDGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1245
Practice Address - Country:US
Practice Address - Phone:440-213-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0800173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340720558Medicaid