Provider Demographics
NPI:1689757346
Name:WALTERS, SUSAN ADELE (MFT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ADELE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RACING WIND
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5480
Mailing Address - Country:US
Mailing Address - Phone:949-278-1114
Mailing Address - Fax:
Practice Address - Street 1:17542 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:949-278-1114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34665106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist