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General NPI Number Information
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NPI Number | 1336255801
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Entity Type | Individual
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Provider Name | ERICA L WALWORTH MS LMFT CEDS RDN LD
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Gender | Female
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 08/15/2019
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Provider Practice Location Address
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Address Line | 412 S SCOTT RD
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City | FORT WAYNE
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State | IN
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Zip | 46814
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Country | US
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Telephone | 260-358-7180
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Fax |
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Provider Business Mailing Address
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Address Line | 11330 EAGLE CREST TRL
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City | FORT WAYNE
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State | IN
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Zip | 46845-1186
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Country | US
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Telephone | 260-489-9009
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Fax | 260-489-5057
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 37001673A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35001890A
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License Number State | IN
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