MEDICARE: MARSHELL SUNNATTA WALTERS IMF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	IMF 52514	CA
2	1041C0700X	Clinical Social Worker	IMF 52514	CA
3	101YM0800X	Mental Health Counselor		AZ

General Provider Information

NPI Number	:	1205974664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARSHELL SUNNATTA WALTERS IMF

Provider Business Mailing Address
First Line	:	3125 W DURANGO ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-6217
Country	:	US
Telephone Number	:	602-372-7226
Fax Number	:

Provider Business Practice Location Address
First Line	:	3125 W DURANGO ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-6217
Country	:	US
Telephone Number	:	602-372-7226
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	10/01/2008

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