Basic Information
Provider Information | |||||||||
NPI: | 1770246290 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALTERS | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | JILL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCVAN | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | JILL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7731 OLD CANTON RD STE B | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MS | ||||||||
PostalCode: | 391106115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014990935 | ||||||||
FaxNumber: | 6014990936 | ||||||||
Practice Location | |||||||||
Address1: | 401 BAPTIST DR STE 301 | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MS | ||||||||
PostalCode: | 391102012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6014990935 | ||||||||
FaxNumber: | 6014990936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2021 | ||||||||
LastUpdateDate: | 10/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | M9149 | MS | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.