Provider Demographics
NPI:1205195294
Name:WALTERS, TIMOTHY R (LPC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1505
Mailing Address - Country:US
Mailing Address - Phone:218-834-5520
Mailing Address - Fax:218-834-4264
Practice Address - Street 1:1401 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2407
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional