Provider Demographics
NPI:1659872646
Name:WALTER, ERICA TRAVONNE
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:TRAVONNE
Last Name:WALTER
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 1:6151 W GRAYS GAP RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7031
Mailing Address - Country:US
Mailing Address - Phone:479-713-9879
Mailing Address - Fax:
Practice Address - Street 1:1845 N GREEN ACRES RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2615
Practice Address - Country:US
Practice Address - Phone:479-713-9879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1704206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health