Healthcare Provider Details

I. General information

NPI: 1225045081
Provider Name (Legal Business Name): SUSAN WALTERS M.A., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

601 W SAN MATEO RD APT 195
SANTA FE NM
87505-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-9799
  • Fax:
Mailing address:
  • Phone: 505-989-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0093441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: