Provider Demographics
NPI:1134162365
Name:WALTERS, KENNETH S (PH,D)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FARONE DR
Mailing Address - Street 2:APT B-11
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-1316
Mailing Address - Country:US
Mailing Address - Phone:607-267-7480
Mailing Address - Fax:
Practice Address - Street 1:15 FARONE DR APT B11
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-1337
Practice Address - Country:US
Practice Address - Phone:607-267-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098303OtherANTHEM LEGACY NUMBER
ME403260099Medicaid
ME403260099Medicaid