Provider Demographics
NPI:1003183088
Name:NIELSON, WALTER WILLIAM JR
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:WILLIAM
Last Name:NIELSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 TROPAZ LN
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8411
Mailing Address - Country:US
Mailing Address - Phone:192-596-1786
Mailing Address - Fax:
Practice Address - Street 1:1234 EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5711
Practice Address - Country:US
Practice Address - Phone:707-439-7830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF78099101YM0800X
CA116511101YM0800X, 106H00000X
CA132820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health