Provider Demographics
NPI:1104974377
Name:WALTERS, TERRY LYNNE (PHD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LYNNE
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 1:517 HARWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4109
Mailing Address - Country:US
Mailing Address - Phone:817-485-9003
Mailing Address - Fax:817-788-2880
Practice Address - Street 1:517 HARWOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4109
Practice Address - Country:US
Practice Address - Phone:817-485-9003
Practice Address - Fax:817-788-2880
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23114103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG63COtherBCBS PROVIDER NUMBER
TX00G63CMedicare ID - Type UnspecifiedPROVIDER NUMBER