Provider Demographics
NPI:1922028737
Name:WALTER, MISTY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:WALTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LYNN
Other - Last Name:KLINGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:900 BEASLEY ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4266
Mailing Address - Country:US
Mailing Address - Phone:859-254-1035
Mailing Address - Fax:859-254-2075
Practice Address - Street 1:57 DORA LANE
Practice Address - Street 2:
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144
Practice Address - Country:US
Practice Address - Phone:606-473-7333
Practice Address - Fax:606-473-7335
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid
000000346980OtherANTHEM BCBS
11688094OtherCAQH
1982615043OtherGRP NPI
1221659OtherCHA
P00372124OtherPALMETTO - RR MCR
11688094OtherCAQH