Provider Demographics
NPI:1043574908
Name:WALTER, KATHLEEN (MSED)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:NAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:253 SAGAMORE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3553
Mailing Address - Country:US
Mailing Address - Phone:631-828-8602
Mailing Address - Fax:631-473-5688
Practice Address - Street 1:253 SAGAMORE HILLS DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3553
Practice Address - Country:US
Practice Address - Phone:631-828-8602
Practice Address - Fax:631-473-5688
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist