Provider Demographics
NPI:1801037189
Name:VINCENT, WALTER W
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:W
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-0098
Mailing Address - Country:US
Mailing Address - Phone:252-477-0008
Mailing Address - Fax:252-477-0008
Practice Address - Street 1:403 E NASH ST
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2461
Practice Address - Country:US
Practice Address - Phone:252-477-0008
Practice Address - Fax:252-303-0321
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3533101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health