Provider Demographics
NPI:1477658680
Name:BROWN, WALTER (PHD)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:BROWN
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 1:5800 HANNUM AVE.
Mailing Address - Street 2:STE 100
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:310-410-9504
Mailing Address - Fax:310-410-9507
Practice Address - Street 1:5800 HANNUM AVE.
Practice Address - Street 2:STE 100
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-410-9504
Practice Address - Fax:310-410-9507
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19358103TC0700X
CAPSY19358103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFC392AOtherMEDICARE PTAN
CAPSY 193580Medicaid