Provider Demographics
NPI:1285910299
Name:WALTERS, MISTY JEAN (LCSW-R)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:JEAN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6884 NICKIS LN
Mailing Address - Street 2:APT 3
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-6527
Mailing Address - Country:US
Mailing Address - Phone:716-304-6609
Mailing Address - Fax:
Practice Address - Street 1:1325 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1988
Practice Address - Country:US
Practice Address - Phone:716-479-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083955104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker