MEDICARE: LAURIE WALTERS MSW, LISW

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639302284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE WALTERS MSW, LISW

Provider Business Mailing Address
First Line	:	111 W 15TH ST
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52803-4609
Country	:	US
Telephone Number	:	563-322-7419
Fax Number	:	563-322-5339

Provider Business Practice Location Address
First Line	:	111 W 15TH ST
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52803-4609
Country	:	US
Telephone Number	:	563-322-7419
Fax Number	:	563-322-5339

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

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	08/31/2009

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