Healthcare Provider Details

I. General information

NPI: 1508350851
Provider Name (Legal Business Name): MR. AUSTIN TANAKA WALLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY STE 300
SAN DIEGO CA
92102-4550
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY STE 300
SAN DIEGO CA
92102-4550
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-2168
  • Fax: 619-398-2168
Mailing address:
  • Phone: 193-982-1566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberF5130372
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: