Basic Information
| Provider Information | |||||||||
| NPI: | 1609972132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8501 HARCOURT RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178759105 | ||||||||
| FaxNumber: | 3178758638 | ||||||||
| Practice Location | |||||||||
| Address1: | 8501 HARCOURT RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178759105 | ||||||||
| FaxNumber: | 3178758638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 31000516A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | 31000516A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200037030 | 05 | IN | MEDICAID | 000000186321 | 01 | ANTHEM HEALTH PLAN | OTHER |