Provider Demographics
NPI:1619283801
Name:WALTERS, MYRON (MFT)
Entity Type:Individual
Prefix:MR
First Name:MYRON
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 LINCOLN AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2121
Mailing Address - Country:US
Mailing Address - Phone:415-686-3445
Mailing Address - Fax:
Practice Address - Street 1:1368 LINCOLN AVE STE 212
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2121
Practice Address - Country:US
Practice Address - Phone:415-686-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48872106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist