Healthcare Provider Details

I. General information

NPI: 1417711888
Provider Name (Legal Business Name): NATHAN LAMAR WALSH-HAINES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 LAUREL ST
SAN DIEGO CA
92101-1634
US

IV. Provider business mailing address

545 LAUREL ST
SAN DIEGO CA
92101-1634
US

V. Phone/Fax

Practice location:
  • Phone: 619-233-4399
  • Fax: 619-233-0453
Mailing address:
  • Phone: 619-233-4399
  • Fax: 619-233-0453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19046
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: