Provider Demographics
NPI:1619455490
Name:WALTERS, BAILIE (RBT)
Entity Type:Individual
Prefix:
First Name:BAILIE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4956 N CHRISTIANA AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4956 N CHRISTIANA AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5079
Practice Address - Country:US
Practice Address - Phone:828-361-9423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-59977106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician