Healthcare Provider Details

I. General information

NPI: 1285412551
Provider Name (Legal Business Name): MAX WALZER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 PROSPERITY LAKE DR # 101
ST AUGUSTINE FL
32092-5045
US

IV. Provider business mailing address

287 TIERRA CV
ST JOHNS FL
32259-1204
US

V. Phone/Fax

Practice location:
  • Phone: 904-370-3420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: