Provider Demographics
NPI:1932488426
Name:WALTERS, JOHN L (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LCSW
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 872
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-0872
Mailing Address - Country:US
Mailing Address - Phone:435-817-8228
Mailing Address - Fax:
Practice Address - Street 1:134 W 1180 N
Practice Address - Street 2:SUITE 4
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1483
Practice Address - Country:US
Practice Address - Phone:435-817-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6338616-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical