Provider Demographics
NPI:1679161491
Name:PHYLLIS WALTERS, PH.D.
Entity Type:Organization
Organization Name:PHYLLIS WALTERS, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:BIANCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-297-1508
Mailing Address - Street 1:9248 CYPRESS DR N
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5440
Mailing Address - Country:US
Mailing Address - Phone:239-297-1508
Mailing Address - Fax:
Practice Address - Street 1:9220 BONITA BEACH RD SE STE 222
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4235
Practice Address - Country:US
Practice Address - Phone:239-404-9396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health