Provider Demographics
NPI:1043887094
Name:WALTERS, BRENT R
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HICKERSON ST APT 702
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-2791
Mailing Address - Country:US
Mailing Address - Phone:193-644-5951
Mailing Address - Fax:
Practice Address - Street 1:1712 N FRAZIER ST STE 208
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-1380
Practice Address - Country:US
Practice Address - Phone:936-445-9512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist