Provider Demographics
NPI:1225199748
Name:ODETS, WALT WHITMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALT
Middle Name:WHITMAN
Last Name:ODETS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 FLORENCE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2004
Mailing Address - Country:US
Mailing Address - Phone:510-845-4628
Mailing Address - Fax:
Practice Address - Street 1:2904 FLORENCE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2004
Practice Address - Country:US
Practice Address - Phone:510-845-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12715103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL127150Medicare ID - Type Unspecified