Provider Demographics
NPI:1093853103
Name:VICTOR, MARIO WALTHER (MSW)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:WALTHER
Last Name:VICTOR
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-498-2890
Mailing Address - Fax:
Practice Address - Street 1:39650 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2223
Practice Address - Country:US
Practice Address - Phone:510-498-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical