Provider Demographics
NPI:1962452284
Name:ELAM, WALTER LE RROY III
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LE RROY
Last Name:ELAM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-1227
Mailing Address - Country:US
Mailing Address - Phone:251-990-3596
Mailing Address - Fax:
Practice Address - Street 1:761 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1715
Practice Address - Country:US
Practice Address - Phone:251-928-4750
Practice Address - Fax:251-990-2560
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist