Healthcare Provider Details

I. General information

NPI: 1477546190
Provider Name (Legal Business Name): PAUL ANDREW WALTERS III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3643 WALTON WAY EXT
AUGUSTA GA
30909-4507
US

IV. Provider business mailing address

3333 WALTON WAY
AUGUSTA GA
30909-4529
US

V. Phone/Fax

Practice location:
  • Phone: 706-729-9595
  • Fax: 706-729-0332
Mailing address:
  • Phone: 706-729-9595
  • Fax: 706-729-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002120
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: