Provider Demographics
NPI:1316497043
Name:WALTERS, MICHAEL (LMSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-2305
Mailing Address - Country:US
Mailing Address - Phone:516-526-1133
Mailing Address - Fax:
Practice Address - Street 1:4271 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5708
Practice Address - Country:US
Practice Address - Phone:516-520-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0948011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY094801OtherLMSW