Provider Demographics
NPI:1235224882
Name:WALTHER, DIANA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:L
Last Name:WALTHER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 LEE STREET
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520
Mailing Address - Country:US
Mailing Address - Phone:912-265-0007
Mailing Address - Fax:912-261-0593
Practice Address - Street 1:1421 LEE STREET
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-265-0007
Practice Address - Fax:912-261-0593
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002320103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10049299OtherAMERIGROUP
GA52769914OtherBLUE CROSS BLUE SHIELD
GA68BBGGXMedicare ID - Type Unspecified
GAS60076Medicare UPIN