Provider Demographics
NPI:1194383802
Name:WALTERS, ENEZIAH
Entity type:Individual
Prefix:
First Name:ENEZIAH
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1657
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:
Practice Address - Street 1:2111 UNIVERSITY PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6907
Practice Address - Country:US
Practice Address - Phone:517-512-5289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801108006104100000X
MI6801102859104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker