Healthcare Provider Details

I. General information

NPI: 1679161491
Provider Name (Legal Business Name): PHYLLIS WALTERS, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 BONITA BEACH RD SE STE 222
BONITA SPRINGS FL
34135-4235
US

IV. Provider business mailing address

9248 CYPRESS DR N
FORT MYERS FL
33967-5440
US

V. Phone/Fax

Practice location:
  • Phone: 239-404-9396
  • Fax:
Mailing address:
  • Phone: 239-297-1508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCO BIANCHI
Title or Position: BILLING MANAGER
Credential:
Phone: 239-297-1508