Provider Demographics
NPI:1023358314
Name:WALTERS, CAROLE LYNN (LMSW, BFA)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:LYNN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LMSW, BFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2519
Mailing Address - Country:US
Mailing Address - Phone:616-451-9650
Mailing Address - Fax:
Practice Address - Street 1:959 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2519
Practice Address - Country:US
Practice Address - Phone:616-451-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL23957211041C0700X, 101YM0800X, 101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376866160Medicaid
MI6949Medicare Oscar/Certification