Healthcare Provider Details

I. General information

NPI: 1700134020
Provider Name (Legal Business Name): ERNEST WALLWORK PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 DAVENPORT ST NW
WASHINGTON DC
20008-2116
US

IV. Provider business mailing address

3021 DAVENPORT ST NW
WASHINGTON DC
20008-2116
US

V. Phone/Fax

Practice location:
  • Phone: 202-244-7919
  • Fax:
Mailing address:
  • Phone: 202-244-7919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000175-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number74
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: