Provider Demographics
NPI:1467824227
Name:WALTERS, STEPHANIA ROMAINE
Entity type:Individual
Prefix:
First Name:STEPHANIA
Middle Name:ROMAINE
Last Name:WALTERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4581 AMANDA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6050
Mailing Address - Country:US
Mailing Address - Phone:941-549-3817
Mailing Address - Fax:
Practice Address - Street 1:18245 PAULSON DR STE 104
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-1019
Practice Address - Country:US
Practice Address - Phone:813-528-7048
Practice Address - Fax:855-610-2343
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLRBT-21-161688106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110001100Medicaid