Provider Demographics
NPI:1942498639
Name:WALTERS, MARY L (LD, RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7082 QUAIL LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9389
Mailing Address - Country:US
Mailing Address - Phone:419-349-8000
Mailing Address - Fax:419-536-5038
Practice Address - Street 1:7082 QUAIL LAKES DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9389
Practice Address - Country:US
Practice Address - Phone:419-349-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 3747P1801X, 376J00000X
OHOH 126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192244Medicaid
OH4809121OtherOHIO DEPT. OF DEVELOPMENTAL DISABILITIES