Healthcare Provider Details

I. General information

NPI: 1255229019
Provider Name (Legal Business Name): MR. MICHAEL WALTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 COUNTY COMPLEX DR
CANANDAIGUA NY
14424-9505
US

IV. Provider business mailing address

31 RADCLIFFE RD
ROCHESTER NY
14617-2711
US

V. Phone/Fax

Practice location:
  • Phone: 585-394-7500
  • Fax:
Mailing address:
  • Phone: 585-755-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP136239
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: