MEDICARE: MRS. WALTERRA MARIE NICOLE MORRIS

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1902388309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WALTERRA MARIE NICOLE MORRIS

Provider Business Mailing Address
First Line	:	601 XENIA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-1825
Country	:	US
Telephone Number	:	937-496-2032
Fax Number	:	937-496-2028

Provider Business Practice Location Address
First Line	:	601 XENIA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-1825
Country	:	US
Telephone Number	:	937-496-2032
Fax Number	:	937-496-2028

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

Provider Enumeration Date	:	08/31/2018
Last Update Date	:	08/31/2018

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