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General NPI Number Information
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NPI Number | 1679161491
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Entity Type | Organization
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Legal Business Name | PHYLLIS WALTERS, PH.D.
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Dates
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Enumeration Date | 01/07/2021
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Last Update Date | 01/07/2021
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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 | 9248 CYPRESS DR N
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City | FORT MYERS
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State | FL
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Zip | 33967-5440
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Country | US
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Telephone | 239-297-1508
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MARCO BIANCHI
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Credential |
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Telephone | 239-297-1508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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