Provider Demographics
NPI:1326684044
Name:WALTERS, PHYLLIS ANNETTE
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANNETTE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16128 PARQUE LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-2816
Mailing Address - Country:US
Mailing Address - Phone:239-404-9396
Mailing Address - Fax:
Practice Address - Street 1:9220 BONITA BEACH RD SE STE 222
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4235
Practice Address - Country:US
Practice Address - Phone:239-404-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS756103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist