Healthcare Provider Details

I. General information

NPI: 1144690918
Provider Name (Legal Business Name): MOLLY ANNE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 BLAKE ST
DENVER CO
80205-2406
US

IV. Provider business mailing address

3425 BLAKE ST
DENVER CO
80205-2406
US

V. Phone/Fax

Practice location:
  • Phone: 720-419-2187
  • Fax: 720-491-1076
Mailing address:
  • Phone: 720-419-2187
  • Fax: 720-491-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-24670
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: