Basic Information
Provider Information | |||||||||
NPI: | 1215407416 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALTERS | ||||||||
FirstName: | CANDY | ||||||||
MiddleName: | RENITA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCOTT | ||||||||
OtherFirstName: | CANDY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3118 H G MOSLEY PKWY | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | TX | ||||||||
PostalCode: | 756052941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9032001433 | ||||||||
FaxNumber: | 9034054047 | ||||||||
Practice Location | |||||||||
Address1: | 3118 H G MOSLEY PKWY | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | TX | ||||||||
PostalCode: | 756052941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9032001433 | ||||||||
FaxNumber: | 9034054047 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2018 | ||||||||
LastUpdateDate: | 08/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 62377 | TX | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.