Provider Demographics
NPI:1902384704
Name:WALTERS, KELLY DAVID (LMHCA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAVID
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 S GRAND BLVD UNIT 8473
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-2681
Mailing Address - Country:US
Mailing Address - Phone:509-570-5155
Mailing Address - Fax:
Practice Address - Street 1:316 W BOONE AVE STE 577
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2346
Practice Address - Country:US
Practice Address - Phone:509-385-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60776492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health