Provider Demographics
NPI:1689724890
Name:WALTERS, IRENA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IRENA
Middle Name:M
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 W WINNEMAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1815
Mailing Address - Country:US
Mailing Address - Phone:773-561-9773
Mailing Address - Fax:773-561-9266
Practice Address - Street 1:9245 CALUMET AVE
Practice Address - Street 2:SUITE 201C
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-836-0966
Practice Address - Fax:773-561-9266
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040333103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31604340OtherBCBS OF IL
017597OtherVALUE OPTIONS