Provider Demographics
NPI:1043926322
Name:WALTER, KENNETH PHILLIP JR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PHILLIP
Last Name:WALTER
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 1:313 KENDAL ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3960
Mailing Address - Country:US
Mailing Address - Phone:707-330-7904
Mailing Address - Fax:888-356-3203
Practice Address - Street 1:313 KENDAL ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3960
Practice Address - Country:US
Practice Address - Phone:707-330-7904
Practice Address - Fax:888-356-3203
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health