Basic Information
Provider Information | |||||||||
NPI: | 1578811055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALTERS | ||||||||
FirstName: | JODI | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSSA, LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KOVACH | ||||||||
OtherFirstName: | JODI | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6753 STATE RD | ||||||||
Address2: |   | ||||||||
City: | PARMA | ||||||||
State: | OH | ||||||||
PostalCode: | 441344517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163190693 | ||||||||
FaxNumber: | 4408431626 | ||||||||
Practice Location | |||||||||
Address1: | 6753 STATE RD | ||||||||
Address2: |   | ||||||||
City: | PARMA | ||||||||
State: | OH | ||||||||
PostalCode: | 441344517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163190693 | ||||||||
FaxNumber: | 4408431626 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2012 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S0901450 | OH | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.2002321 | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.