Provider Demographics
NPI:1588642805
Name:WALTERS, MARY ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:8950 VILLA LA LOLLA DR.
Mailing Address - Street 2:STE. C112
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-643-9771
Mailing Address - Fax:858-455-7612
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE C112
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1703
Practice Address - Country:US
Practice Address - Phone:858-643-9771
Practice Address - Fax:858-455-7612
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS145661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical