Provider Demographics
NPI:1295070514
Name:WALTERS, KIEL B (LISCW)
Entity type:Individual
Prefix:
First Name:KIEL
Middle Name:B
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LISCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WILLSON RD
Mailing Address - Street 2:210
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1332
Mailing Address - Country:US
Mailing Address - Phone:612-787-2475
Mailing Address - Fax:
Practice Address - Street 1:5200 WILLSON RD
Practice Address - Street 2:210
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1332
Practice Address - Country:US
Practice Address - Phone:612-787-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical