Provider Demographics
NPI:1629197215
Name:WALTER, JOHN MARTIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:WALTER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 CLAY ST
Mailing Address - Street 2:270S
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-5217
Mailing Address - Country:US
Mailing Address - Phone:510-587-5002
Mailing Address - Fax:
Practice Address - Street 1:1301 CLAY ST
Practice Address - Street 2:270S
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612
Practice Address - Country:US
Practice Address - Phone:510-587-5002
Practice Address - Fax:510-287-2417
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW173071041C0700X
CALCS 256521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5830OtherSFGH INTERNAL USE ONLY
5830OtherCBHS INTERNAL USE ONLY-COMMERCIAL NUMBER