Provider Demographics
NPI:1083978548
Name:WALTERS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7128 SEA PINE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4138
Mailing Address - Country:US
Mailing Address - Phone:630-205-4356
Mailing Address - Fax:317-842-4428
Practice Address - Street 1:7128 SEA PINE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4138
Practice Address - Country:US
Practice Address - Phone:630-205-4356
Practice Address - Fax:317-842-4428
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0125063103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst