Basic Information
| Provider Information | |||||||||
| NPI: | 1407364185 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | ALEXANDRIA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 PINE ST | ||||||||
| Address2: | |||||||||
| City: | CHESANING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486161252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893232090 | ||||||||
| FaxNumber: | 9893233991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 RIDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898356333 | ||||||||
| FaxNumber: | 9893233991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-22-57908 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.