Healthcare Provider Details

I. General information

NPI: 1689724890
Provider Name (Legal Business Name): IRENA M WALTERS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 CALUMET AVE SUITE 201C
MUNSTER IN
46321
US

IV. Provider business mailing address

2245 W WINNEMAC AVE
CHICAGO IL
60625-1815
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-0966
  • Fax: 773-561-9266
Mailing address:
  • Phone: 773-561-9773
  • Fax: 773-561-9266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040333
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: