Provider Demographics
NPI:1760719975
Name:WALTERS, MARVIN (MA)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 PLEASANT HOLLOW DR APT 58
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-4398
Mailing Address - Country:US
Mailing Address - Phone:901-565-0418
Mailing Address - Fax:
Practice Address - Street 1:3810 WINCHESTER RD
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6045
Practice Address - Country:US
Practice Address - Phone:901-369-1420
Practice Address - Fax:901-369-1433
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator