Provider Demographics
NPI:1992109599
Name:WALTER, THOMAS (MS, LAC, LISAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WALTER
Suffix:
Gender:M
Credentials:MS, LAC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 N ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5808
Mailing Address - Country:US
Mailing Address - Phone:520-423-2121
Mailing Address - Fax:
Practice Address - Street 1:1901 N TREKELL RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1770
Practice Address - Country:US
Practice Address - Phone:520-421-3321
Practice Address - Fax:520-421-0087
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10457101YA0400X
AZLAC-14414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health