Healthcare Provider Details

I. General information

NPI: 1619314697
Provider Name (Legal Business Name): MALLORY WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 12/29/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LINCOLN AVE STE. 206
NAPA CA
94558-4900
US

IV. Provider business mailing address

368 FELL ST
SAN FRANCISCO CA
94102-5144
US

V. Phone/Fax

Practice location:
  • Phone: 415-861-0828
  • Fax: 415-861-0257
Mailing address:
  • Phone: 415-861-0828
  • Fax: 415-861-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT125970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: