Provider Demographics
NPI:1164773941
Name:WALTERS, LISA JOY (MSED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JOY
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ASHFORD DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKEGROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755
Mailing Address - Country:US
Mailing Address - Phone:631-588-5176
Mailing Address - Fax:
Practice Address - Street 1:6 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2808
Practice Address - Country:US
Practice Address - Phone:631-588-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist