Provider Demographics
NPI:1083801997
Name:WALLINGFORD, NANCY (MA, MFT MFC #51404)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WALLINGFORD
Suffix:
Gender:F
Credentials:MA, MFT MFC #51404
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 41ST AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3930
Mailing Address - Country:US
Mailing Address - Phone:831-713-7546
Mailing Address - Fax:
Practice Address - Street 1:1395 41ST AVE
Practice Address - Street 2:SUITE E
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3930
Practice Address - Country:US
Practice Address - Phone:831-713-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC #51404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT514040OtherBLUE SHIELD OF CALIFORNIA
ZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#