Provider Demographics
NPI:1619314697
Name:WALTERS, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WALTERS
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 1:368 FELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:415-861-0257
Practice Address - Street 1:1100 LINCOLN AVE
Practice Address - Street 2:STE. 206
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4900
Practice Address - Country:US
Practice Address - Phone:415-861-0828
Practice Address - Fax:415-861-0257
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CALMFT125970106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator