Healthcare Provider Details

I. General information

NPI: 1033718648
Provider Name (Legal Business Name): MARTIN EDWARD WALTERS SUDCC1-7897
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 CIVIC CT # 100
CONCORD CA
94520-5290
US

IV. Provider business mailing address

1877 ELDERWOOD DR
CONCORD CA
94519-1101
US

V. Phone/Fax

Practice location:
  • Phone: 925-849-6173
  • Fax: 925-849-6832
Mailing address:
  • Phone: 925-497-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number7897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: