Healthcare Provider Details

I. General information

NPI: 1194635870
Provider Name (Legal Business Name): WALTER JAMES VENERABLE III PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 S MANTHEY RD
FRENCH CAMP CA
95231-9518
US

IV. Provider business mailing address

11958 ARMANDI WAY
RANCHO CORDOVA CA
95742-6937
US

V. Phone/Fax

Practice location:
  • Phone: 916-507-5579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: