Provider Demographics
NPI:1265123863
Name:WALTERS COLLABORATIVE, LLC
Entity type:Organization
Organization Name:WALTERS COLLABORATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP/BUSINESS OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTEL
Authorized Official - Middle Name:CRAIN
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:601-597-4992
Mailing Address - Street 1:6196B MS HIGHWAY 567
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-5283
Mailing Address - Country:US
Mailing Address - Phone:601-597-4992
Mailing Address - Fax:
Practice Address - Street 1:6196B MS HIGHWAY 567
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-5283
Practice Address - Country:US
Practice Address - Phone:601-597-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech