Provider Demographics
NPI:1376161836
Name:STEELE, WALTER KEVIN (EMT P120704)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:KEVIN
Last Name:STEELE
Suffix:
Gender:M
Credentials:EMT P120704
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5428 FRIENDLY BAPTIST CH RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-7797
Mailing Address - Country:US
Mailing Address - Phone:704-989-6180
Mailing Address - Fax:
Practice Address - Street 1:5428 FRIENDLY BAPTIST CH RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-7797
Practice Address - Country:US
Practice Address - Phone:704-989-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106500000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP120704OtherEMT