Provider Demographics
NPI:1447640107
Name:WALTERS, RANDY (MED, EDS)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1421
Mailing Address - Country:US
Mailing Address - Phone:937-332-6730
Mailing Address - Fax:
Practice Address - Street 1:701 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1421
Practice Address - Country:US
Practice Address - Phone:937-332-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20973784103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOH3053643Medicaid