Provider Demographics
NPI:1003459777
Name:OBI, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:OBI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 BROOKSIDE OAKS
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5168
Mailing Address - Country:US
Mailing Address - Phone:443-722-1360
Mailing Address - Fax:
Practice Address - Street 1:4201 BROOKSIDE OAKS
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5168
Practice Address - Country:US
Practice Address - Phone:443-722-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities