MEDICARE: DAVID JOHN WOLTER M.A. MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC49749	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MFC49749	OTHER	CA	BBS

General Provider Information

NPI Number	:	1679736250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JOHN WOLTER M.A. MFT

Provider Business Mailing Address
First Line	:	264 CLOVIS AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-1115
Country	:	US
Telephone Number	:	559-545-7087
Fax Number	:	559-324-6565

Provider Business Practice Location Address
First Line	:	264 CLOVIS AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-1115
Country	:	US
Telephone Number	:	559-545-7087
Fax Number	:	559-324-6565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2008
Last Update Date	:	03/31/2017

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