Provider Demographics
NPI:1922986421
Name:WALTERS, MACKENZIE GRACE (MS/CAGS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:MS/CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 SALT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-8500
Mailing Address - Country:US
Mailing Address - Phone:585-545-0958
Mailing Address - Fax:
Practice Address - Street 1:202 KEELEY ST
Practice Address - Street 2:
Practice Address - City:EDINBURGH
Practice Address - State:IN
Practice Address - Zip Code:46124-1383
Practice Address - Country:US
Practice Address - Phone:812-526-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN000044987103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool