Provider Demographics
NPI:1033718648
Name:WALTERS, MARTIN EDWARD (SUDCC1-7897)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:EDWARD
Last Name:WALTERS
Suffix:
Gender:M
Credentials:SUDCC1-7897
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 ELDERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-1101
Mailing Address - Country:US
Mailing Address - Phone:925-497-8502
Mailing Address - Fax:
Practice Address - Street 1:1470 CIVIC CT # 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5290
Practice Address - Country:US
Practice Address - Phone:925-849-6173
Practice Address - Fax:925-849-6832
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)