Provider Demographics
NPI:1336255801
Name:WALWORTH, ERICA L (MS LMFT CEDS RDN LD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:WALWORTH
Suffix:
Gender:F
Credentials:MS LMFT CEDS RDN LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11330 EAGLE CREST TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1186
Mailing Address - Country:US
Mailing Address - Phone:260-489-9009
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:412 S SCOTT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814
Practice Address - Country:US
Practice Address - Phone:260-358-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001673A133V00000X
IN35001890A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
0893263OtherAMERICAN DIETETIC ASSOCIA
893263OtherCDR