Provider Demographics
NPI:1336616226
Name:WALTERS, KELLY (MS, LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-0667
Mailing Address - Country:US
Mailing Address - Phone:218-828-2027
Mailing Address - Fax:218-829-1473
Practice Address - Street 1:101 DEHLER DR
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4407
Practice Address - Country:US
Practice Address - Phone:320-253-3512
Practice Address - Fax:320-253-1037
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist