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General NPI Number Information
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NPI Number | 1326684044
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Entity Type | Individual
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Provider Name | DR. PHYLLIS ANNETTE WALTERS
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Gender | Female
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Dates
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Enumeration Date | 11/19/2019
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Last Update Date | 11/19/2019
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Provider Practice Location Address
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Address Line | 9220 BONITA BEACH RD SE STE 222
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City | BONITA SPRINGS
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State | FL
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Zip | 34135-4235
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Country | US
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Telephone | 239-404-9396
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Fax |
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Provider Business Mailing Address
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Address Line | 16128 PARQUE LN
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City | NAPLES
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State | FL
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Zip | 34110-2816
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Country | US
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Telephone | 239-404-9396
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | SS756
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | SS756
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License Number State | FL
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