Healthcare Provider Details

I. General information

NPI: 1962452284
Provider Name (Legal Business Name): DR. WALTER LE RROY ELAM III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MIDDLE ST
FAIRHOPE AL
36532-1715
US

IV. Provider business mailing address

153 ORANGE AVE
FAIRHOPE AL
36532-1227
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-4750
  • Fax: 251-990-2560
Mailing address:
  • Phone: 251-990-3596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number15
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: