Provider Demographics
NPI:1508402462
Name:WALTERS, MAISHA LO-RAIN
Entity Type:Individual
Prefix:
First Name:MAISHA
Middle Name:LO-RAIN
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 1:227 BLOY ST FL 2
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-2108
Mailing Address - Country:US
Mailing Address - Phone:908-884-8128
Mailing Address - Fax:
Practice Address - Street 1:227 BLOY ST FL 2
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2108
Practice Address - Country:US
Practice Address - Phone:908-884-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00658900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional