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General NPI Number Information
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NPI Number | 1750604583
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Entity Type | Individual
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Provider Name | JOHANNA CHRISTINE WALTHALL PH.D.
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Gender | Female
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Dates
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Enumeration Date | 03/08/2010
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Last Update Date | 12/06/2021
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Provider Practice Location Address
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Address Line | 180 CABRILLO ST APT B19
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City | COSTA MESA
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State | CA
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Zip | 92627-3051
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Country | US
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Telephone | 562-234-7568
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Fax |
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Provider Business Mailing Address
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Address Line | 17046 MARYGOLD AVE
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City | FONTANA
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State | CA
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Zip | 92335-1722
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Country | US
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Telephone | 909-427-6705
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY21948
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License Number State | CA
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