Provider Demographics
NPI:1003388711
Name:NEELY-WALTERS, RENEE MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELLE
Last Name:NEELY-WALTERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 CABOT ST
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-1259
Mailing Address - Country:US
Mailing Address - Phone:202-607-8269
Mailing Address - Fax:
Practice Address - Street 1:5800 8TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1900
Practice Address - Country:US
Practice Address - Phone:202-541-6608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05151103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist