Provider Demographics
NPI:1356981682
Name:WALTERS, BURT ANDRE
Entity type:Individual
Prefix:
First Name:BURT
Middle Name:ANDRE
Last Name:WALTERS
Suffix:
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 1:31040 PARKMONTE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-7906
Mailing Address - Country:US
Mailing Address - Phone:813-598-4225
Mailing Address - Fax:
Practice Address - Street 1:31040 PARKMONTE DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-7906
Practice Address - Country:US
Practice Address - Phone:813-598-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL777423Medicaid