Provider Demographics
NPI:1457893760
Name:WALTER, BETCY
Entity Type:Individual
Prefix:
First Name:BETCY
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21071 SIX LS FARM RD
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9180 ESTERO PARK COMMONS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3218
Practice Address - Country:US
Practice Address - Phone:239-595-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH12169101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health