Provider Demographics
NPI:1952013856
Name:WALTERS, MARLO ELLIS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARLO
Middle Name:ELLIS
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 SATIN LEAF PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8962
Mailing Address - Country:US
Mailing Address - Phone:850-377-4752
Mailing Address - Fax:
Practice Address - Street 1:2837 SATIN LEAF PARK
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-8962
Practice Address - Country:US
Practice Address - Phone:850-377-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200141871A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical