Provider Demographics
NPI:1043660343
Name:WALTERS, HEATH B (PHD)
Entity type:Individual
Prefix:DR
First Name:HEATH
Middle Name:B
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MAIN ST STE 470
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1806
Mailing Address - Country:US
Mailing Address - Phone:208-413-6711
Mailing Address - Fax:
Practice Address - Street 1:504 MAIN ST STE 470
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1806
Practice Address - Country:US
Practice Address - Phone:208-413-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000090001041C0700X
IDLCSW285751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical