Healthcare Provider Details

I. General information

NPI: 1265123863
Provider Name (Legal Business Name): WALTERS COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 NFS 123E RD
ROXIE MS
39661-5176
US

IV. Provider business mailing address

6196B MS HIGHWAY 567
LIBERTY MS
39645-5283
US

V. Phone/Fax

Practice location:
  • Phone: 601-597-4992
  • Fax:
Mailing address:
  • Phone: 601-597-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHANTEL CRAIN WALTERS
Title or Position: SLP/BUSINESS OWNER
Credential: MS, CCC-SLP
Phone: 601-597-4992