Healthcare Provider Details

I. General information

NPI: 1548332778
Provider Name (Legal Business Name): EVA LYNN G WALTHALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14815 SAN PEDRO AVE
SAN ANTONIO TX
78232-3708
US

IV. Provider business mailing address

14815 SAN PEDRO AVE
SAN ANTONIO TX
78232-3708
US

V. Phone/Fax

Practice location:
  • Phone: 210-494-1991
  • Fax: 210-494-7575
Mailing address:
  • Phone: 210-494-1991
  • Fax: 210-494-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6244
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: