Provider Demographics
NPI:1730301128
Name:PEDERSEN, WALTER (CADC II)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3668 SPRUCE AVE
Mailing Address - Street 2:APT. 19
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7497
Mailing Address - Country:US
Mailing Address - Phone:530-388-8085
Mailing Address - Fax:
Practice Address - Street 1:2494 LAKE TAHOE BLVD STE B2
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7142
Practice Address - Country:US
Practice Address - Phone:530-541-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)