MEDICARE: DR. WALTER DACKERMAN RUTHERFORD M.F.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MFT19739	CA

General Provider Information

NPI Number	:	1790950400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER DACKERMAN RUTHERFORD M.F.T.

Provider Business Mailing Address
First Line	:	6540 LUSK BLVD
Second Line	:	SUITE C-159
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-2766
Country	:	US
Telephone Number	:	858-202-1777
Fax Number	:	858-202-1701

Provider Business Practice Location Address
First Line	:	6540 LUSK BLVD
Second Line	:	SUITE C-159
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-2766
Country	:	US
Telephone Number	:	858-202-1777
Fax Number	:	858-202-1701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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