1477542009 NPI number — MRS. LISA MARIE WALTERS OTR/L, CHT

Table of content: MRS. LISA MARIE WALTERS OTR/L, CHT (NPI 1477542009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477542009 NPI number — MRS. LISA MARIE WALTERS OTR/L, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTERS
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMURR
Provider Other First Name:
LISA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477542009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 DOE MEADOW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-2064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-217-0137
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2195 HARRODSBURG RD FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
595-621-9808
Provider Business Practice Location Address Fax Number:
859-257-0573
Provider Enumeration Date:
10/17/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  260440 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 260440 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100632600 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".