Basic Information
| Provider Information | |||||||||
| NPI: | 1922028737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KLINGLER | ||||||||
| OtherFirstName: | MISTY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 BEASLEY ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405094266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592541035 | ||||||||
| FaxNumber: | 8592542075 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 DORA LANE | ||||||||
| Address2: | |||||||||
| City: | GREENUP | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064737333 | ||||||||
| FaxNumber: | 6064737335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1258 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 30610026 | 05 | KY | MEDICAID | 000000346980 | 01 | ANTHEM BCBS | OTHER | 11688094 | 01 | CAQH | OTHER | 1982615043 | 01 | GRP NPI | OTHER | 1221659 | 01 | CHA | OTHER | P00372124 | 01 | PALMETTO - RR MCR | OTHER |