Provider Demographics
NPI:1508650433
Name:WALTERS, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
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 1:15817 TURNEY RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4859
Mailing Address - Country:US
Mailing Address - Phone:216-490-9059
Mailing Address - Fax:
Practice Address - Street 1:12395 MCCRACKEN RD STE A
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2946
Practice Address - Country:US
Practice Address - Phone:216-587-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator