Provider Demographics
NPI:1609037910
Name:GWALTNEY, MARY V (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:V
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 AMERICAN RIVER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-5753
Mailing Address - Country:US
Mailing Address - Phone:916-972-9400
Mailing Address - Fax:916-972-9500
Practice Address - Street 1:3416 AMERICAN RIVER DR
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-5753
Practice Address - Country:US
Practice Address - Phone:916-972-9400
Practice Address - Fax:916-972-9500
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP2540101Y00000X, 103TC2200X
CALEP254103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral