Healthcare Provider Details

I. General information

NPI: 1023309085
Provider Name (Legal Business Name): EBAN WALTERS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 VETERANS MEMORIAL BLVD SUITE 201
METAIRIE LA
70006-5340
US

IV. Provider business mailing address

7608 WILLOW ST
NEW ORLEANS LA
70118-4052
US

V. Phone/Fax

Practice location:
  • Phone: 504-302-3226
  • Fax: 504-267-0298
Mailing address:
  • Phone: 504-302-3226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1150
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1150
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: