Provider Demographics
NPI:1649572058
Name:WALTERS, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
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 1:211 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2630
Mailing Address - Country:US
Mailing Address - Phone:217-347-1037
Mailing Address - Fax:
Practice Address - Street 1:211 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2630
Practice Address - Country:US
Practice Address - Phone:217-347-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist