Healthcare Provider Details

I. General information

NPI: 1831787746
Provider Name (Legal Business Name): HEIDI C WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 CITY VIEW DR STE 206
EVANSTON WY
82930-5326
US

IV. Provider business mailing address

350 CITY VIEW DR STE 206
EVANSTON WY
82930-5326
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-7915
  • Fax:
Mailing address:
  • Phone: 307-789-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPPC-1226
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: