MEDICARE: DEANDRE WALTER

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1548544539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANDRE WALTER

Provider Business Mailing Address
First Line	:	1805 NE 52ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-7007
Country	:	US
Telephone Number	:	405-255-2874
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 NE 52ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-7007
Country	:	US
Telephone Number	:	405-255-2874
Fax Number	:

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

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	10/07/2011

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Directions to “ DEANDRE WALTER ” Practice Location

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