Provider Demographics
NPI:1881752558
Name:WALTERS, NICOLLE S (PHD)
Entity type:Individual
Prefix:DR
First Name:NICOLLE
Middle Name:S
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77564 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 408
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0484
Mailing Address - Country:US
Mailing Address - Phone:760-898-2968
Mailing Address - Fax:760-345-3888
Practice Address - Street 1:77564 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 408
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0484
Practice Address - Country:US
Practice Address - Phone:760-898-2968
Practice Address - Fax:760-345-3888
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15949103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL159490Medicare ID - Type Unspecified
S62087Medicare UPIN