Provider Demographics
NPI:1114481868
Name:WALTERS, KEITH P
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:P
Last Name:WALTERS
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 1:370 COUNTRY CLUB RD STE A
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8303
Mailing Address - Country:US
Mailing Address - Phone:616-836-2896
Mailing Address - Fax:616-393-2182
Practice Address - Street 1:370 COUNTRY CLUB RD STE A
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-8303
Practice Address - Country:US
Practice Address - Phone:616-836-2896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIN438257405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional