Provider Demographics
NPI:1417571829
Name:WALTER, JOELLEN
Entity Type:Individual
Prefix:
First Name:JOELLEN
Middle Name:
Last Name:WALTER
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 1:17200 WESTGROVE DR APT 2412
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-7135
Mailing Address - Country:US
Mailing Address - Phone:972-841-2861
Mailing Address - Fax:
Practice Address - Street 1:17200 WESTGROVE DR APT 2412
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7135
Practice Address - Country:US
Practice Address - Phone:972-841-2861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79427101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor