Provider Demographics
NPI:1568625747
Name:DIANA L. WALTHER, PH.D. PC
Entity Type:Organization
Organization Name:DIANA L. WALTHER, PH.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-265-0007
Mailing Address - Street 1:1421 LEE ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-7132
Mailing Address - Country:US
Mailing Address - Phone:912-265-0007
Mailing Address - Fax:912-261-0593
Practice Address - Street 1:1421 LEE ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7132
Practice Address - Country:US
Practice Address - Phone:912-265-0007
Practice Address - Fax:912-261-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002320103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10049299OtherAMERIGROUP
GA000829606DMedicaid
GAS60076Medicare UPIN
GA68BBGGXMedicare PIN