Provider Demographics
NPI:1194254177
Name:WALTERS, FAITH SHANNON (LSW)
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:SHANNON
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:SHANNON
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:246 NORTHLAND DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3440
Mailing Address - Country:US
Mailing Address - Phone:330-725-9195
Mailing Address - Fax:
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:330-725-9187
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker