Provider Demographics
NPI:1558502880
Name:WALTHALL, LOUIS (LCSWR, CASAC)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:M
Credentials:LCSWR, CASAC
Other - Prefix:
Other - First Name:LOUIS
Other - Middle Name:C
Other - Last Name:WALTHALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSWR, CASAC
Mailing Address - Street 1:3281 VETERANS MEMORIAL HWY STE E14
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7675
Mailing Address - Country:US
Mailing Address - Phone:631-471-3122
Mailing Address - Fax:
Practice Address - Street 1:3281 VETERANS MEMORIAL HWY STE E14
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7675
Practice Address - Country:US
Practice Address - Phone:631-471-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 051661101YA0400X, 101YM0800X
NY9438101YA0400X
NY0516611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health