Healthcare Provider Details

I. General information

NPI: 1831024389
Provider Name (Legal Business Name): NASTASSIA MARIE MOORE-WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 JOSEPH CT
SAN RAFAEL CA
94903-2664
US

IV. Provider business mailing address

3809 PAINTED PONY RD
EL SOBRANTE CA
94803-2131
US

V. Phone/Fax

Practice location:
  • Phone: 415-720-2029
  • Fax:
Mailing address:
  • Phone: 415-785-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1438180426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: