Basic Information
| Provider Information | |||||||||
| NPI: | 1588647283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 ACADEMY AVE | ||||||||
| Address2: | ACADEMY CROSSING MEDICAL PLAZA | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836404 | ||||||||
| FaxNumber: | 7574830737 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 ACADEMY AVE | ||||||||
| Address2: | ACADEMY CROSSING MEDICAL PLAZA | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836404 | ||||||||
| FaxNumber: | 7574830737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810001355 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 085262 | 01 | VA | SENTARA | OTHER | 007702311 | 05 | VA | MEDICAID | 331838 | 01 | VA | ANTHEM | OTHER |