Healthcare Provider Details

I. General information

NPI: 1295304632
Provider Name (Legal Business Name): NINA REGINA NOELL WALTERMAN AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

IV. Provider business mailing address

1 SAINT VINCENTS DR
SAN RAFAEL CA
94903-1504
US

V. Phone/Fax

Practice location:
  • Phone: 415-507-2000
  • Fax:
Mailing address:
  • Phone: 415-507-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number115712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: