Provider Demographics
NPI:1770512808
Name:HERSING, WALT (LCSW)
Entity type:Individual
Prefix:
First Name:WALT
Middle Name:
Last Name:HERSING
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 FRANKLIN DR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4022
Mailing Address - Country:US
Mailing Address - Phone:321-724-1614
Mailing Address - Fax:321-722-3590
Practice Address - Street 1:2123 FRANKLIN DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4022
Practice Address - Country:US
Practice Address - Phone:321-724-1614
Practice Address - Fax:321-722-3590
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00033171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6179ZOtherBLUE CROSS BLUE SHIELD
FLZ6179ZMedicare ID - Type Unspecified