Healthcare Provider Details

I. General information

NPI: 1659872646
Provider Name (Legal Business Name): MRS. ERICA TRAVONNE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 N GREEN ACRES RD
FAYETTEVILLE AR
72703-2615
US

IV. Provider business mailing address

6151 W GRAYS GAP RD
FAYETTEVILLE AR
72704-7031
US

V. Phone/Fax

Practice location:
  • Phone: 479-713-9879
  • Fax:
Mailing address:
  • Phone: 479-713-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2404012
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: