Provider Demographics
NPI:1992082119
Name:WALTERS, MICHELE MARIE
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:MARIE
Other - Last Name:MCCANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-2921
Mailing Address - Country:US
Mailing Address - Phone:917-533-5971
Mailing Address - Fax:
Practice Address - Street 1:1193 WARBURTON AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1002
Practice Address - Country:US
Practice Address - Phone:914-377-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020010-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist