Provider Demographics
NPI:1902388309
Name:MORRIS, WALTERRA MARIE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:WALTERRA
Middle Name:MARIE NICOLE
Last Name:MORRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WALTERRA
Other - Middle Name:MARIE NICOLE
Other - Last Name:POLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-1825
Mailing Address - Country:US
Mailing Address - Phone:937-496-2032
Mailing Address - Fax:937-496-2028
Practice Address - Street 1:601 XENIA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1825
Practice Address - Country:US
Practice Address - Phone:937-496-2032
Practice Address - Fax:937-496-2028
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health