Healthcare Provider Details

I. General information

NPI: 1144092388
Provider Name (Legal Business Name): SARAH E WALTERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2958 BENSON LN
NORMAL IL
61761-5472
US

IV. Provider business mailing address

2958 BENSON LN
NORMAL IL
61761-5472
US

V. Phone/Fax

Practice location:
  • Phone: 815-243-0177
  • Fax:
Mailing address:
  • Phone: 815-243-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.017903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: