Provider Demographics
NPI:1235492125
Name:VIVIAN, ELIZABETH WALTERS (MA, LPC, PMH-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WALTERS
Last Name:VIVIAN
Suffix:
Gender:F
Credentials:MA, LPC, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3678
Mailing Address - Country:US
Mailing Address - Phone:225-933-2373
Mailing Address - Fax:225-410-2990
Practice Address - Street 1:8631 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3678
Practice Address - Country:US
Practice Address - Phone:225-933-2373
Practice Address - Fax:225-410-2990
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-17
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional