MEDICARE: LAURA WALTERS LCDC III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	081104	OH

General Provider Information

NPI Number	:	1497086060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA WALTERS LCDC III

Provider Business Mailing Address
First Line	:	2600 VICTORY PKWY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45206-1711
Country	:	US
Telephone Number	:	513-751-7747
Fax Number	:	513-751-0180

Provider Business Practice Location Address
First Line	:	5232 STATE ROUTE 63
Second Line	:
City	:	LEBANON
State	:	OH
Zip	:	45036-8202
Country	:	US
Telephone Number	:	513-932-1952
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2010
Last Update Date	:	01/21/2010

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