Provider Demographics
NPI:1437546009
Name:WALTERS, KRISTA (MED, MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MED, MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 62ND ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-9796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3707 62ND ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9796
Practice Address - Country:US
Practice Address - Phone:616-566-2568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist