Healthcare Provider Details

I. General information

NPI: 1225449895
Provider Name (Legal Business Name): NICOLE PRATTE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5490 CLYDE MOORE DR. SUITE C
GROVEPORT OH
43125
US

IV. Provider business mailing address

5490 CLYDE MOORE DR.
GROVEPORT OH
43125
US

V. Phone/Fax

Practice location:
  • Phone: 614-492-2520
  • Fax:
Mailing address:
  • Phone: 614-492-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH1539092
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: