Provider Demographics
NPI:1558767061
Name:WALTHER, EDWARD CHARLES
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
Last Name:WALTHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 E 3RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1630
Mailing Address - Country:US
Mailing Address - Phone:213-620-5712
Mailing Address - Fax:213-621-4155
Practice Address - Street 1:470 E 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1630
Practice Address - Country:US
Practice Address - Phone:213-620-5712
Practice Address - Fax:213-621-4155
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0507811218101YA0400X
171M00000X
CAA050781218172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator