Provider Demographics
NPI:1629411152
Name:WALTERS, BAILEY J
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:J
Last Name:WALTERS
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 1:1425 21ST AVE NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0816
Mailing Address - Country:US
Mailing Address - Phone:701-839-8887
Mailing Address - Fax:701-839-8990
Practice Address - Street 1:1425 21ST AVE NW
Practice Address - Street 2:SUITE A
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0816
Practice Address - Country:US
Practice Address - Phone:701-839-8887
Practice Address - Fax:701-839-8990
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5091104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker