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General NPI Number Information
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NPI Number | 1700124666
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Entity Type | Organization
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Legal Business Name | RANDOLPH WALTERS & ASSOCIATES, LLC
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Dates
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Enumeration Date | 01/27/2013
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Last Update Date | 01/27/2013
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Provider Practice Location Address
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Address Line | 1989 N 63RD ST SUITE 200
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City | PHILADELPHIA
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State | PA
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Zip | 19151-2607
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Country | US
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Telephone | 610-639-1729
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Fax | 215-878-8998
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Provider Business Mailing Address
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Address Line | 1989 N 63RD ST SUITE 200
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City | PHILADELPHIA
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State | PA
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Zip | 19151-2607
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Country | US
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Telephone | 610-639-1729
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Fax | 215-878-8998
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Authorized Official
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Title or Position | FOUNDER/DIRECTOR
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Name | DR. RANDOLPH WINDELL WALTERS
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Credential | PSY.D, LPC
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Telephone | 610-639-1729
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | PC002890
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License Number State | PA
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