Provider Demographics
NPI:1487470209
Name:WALTERS, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WALTERS
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 1:18 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1419
Mailing Address - Country:US
Mailing Address - Phone:757-582-2044
Mailing Address - Fax:
Practice Address - Street 1:825 DILIGENCE DR STE 102B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4229
Practice Address - Country:US
Practice Address - Phone:254-249-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-199602103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst