Provider Demographics
NPI:1518019777
Name:WALLS-JOHNSON, MILDRED NAIMA
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:NAIMA
Last Name:WALLS-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1910
Mailing Address - Country:US
Mailing Address - Phone:510-231-7812
Mailing Address - Fax:510-231-7810
Practice Address - Street 1:84 BROADWAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804
Practice Address - Country:US
Practice Address - Phone:510-231-7812
Practice Address - Fax:510-231-7810
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA87983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health