Provider Demographics
NPI:1679774590
Name:WALTER, VENNARD C JR (DMIN, MA)
Entity Type:Individual
Prefix:DR
First Name:VENNARD
Middle Name:C
Last Name:WALTER
Suffix:JR
Gender:M
Credentials:DMIN, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4805
Mailing Address - Country:US
Mailing Address - Phone:812-945-5611
Mailing Address - Fax:812-945-4812
Practice Address - Street 1:146 CHERRY ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4805
Practice Address - Country:US
Practice Address - Phone:812-945-5611
Practice Address - Fax:812-945-4812
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000951A101YM0800X
KY0038101YP1600X
IN35001012A106H00000X
KY0261106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist