Basic Information
| Provider Information | |||||||||
| NPI: | 1124379391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246326312 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W GEORGE ST | ||||||||
| Address2: | |||||||||
| City: | CARMICHAELS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153201325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249665081 | ||||||||
| FaxNumber: | 7249662414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | PA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1007288440093 | 05 | PA | MEDICAID | 328834A764918 | 01 | PA | VALUE BEHAVIORAL HEALTH | OTHER |