Provider Demographics
NPI:1962522136
Name:WALTERS, SHARON RUTH (PHD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:RUTH
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 E. ANAHEIM ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3408
Mailing Address - Country:US
Mailing Address - Phone:714-968-5653
Mailing Address - Fax:
Practice Address - Street 1:2100 E ANAHEIM ST
Practice Address - Street 2:SUITE B
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3408
Practice Address - Country:US
Practice Address - Phone:714-968-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14387103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY143875Medicaid
CACP14387DMedicare ID - Type Unspecified