=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023309085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EBAN WALTERS PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2011
-----------------------------------------------------
Last Update Date | 06/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 VETERANS MEMORIAL BLVD SUITE 201
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-302-3226
-----------------------------------------------------
Fax | 504-267-0298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7608 WILLOW ST
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70118-4052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-302-3226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 1150
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1150
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------