Healthcare Provider Details

I. General information

NPI: 1679774590
Provider Name (Legal Business Name): VENNARD C WALTER JR. DMIN, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 CHERRY ST
NEW ALBANY IN
47150-4805
US

IV. Provider business mailing address

146 CHERRY ST
NEW ALBANY IN
47150-4805
US

V. Phone/Fax

Practice location:
  • Phone: 812-945-5611
  • Fax: 812-945-4812
Mailing address:
  • Phone: 812-945-5611
  • Fax: 812-945-4812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000951A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0038
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001012A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0261
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: