Provider Demographics
NPI:1790950400
Name:RUTHERFORD, WALTER DACKERMAN (MFT)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:DACKERMAN
Last Name:RUTHERFORD
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 1:6540 LUSK BLVD
Mailing Address - Street 2:SUITE C-159
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2766
Mailing Address - Country:US
Mailing Address - Phone:858-202-1777
Mailing Address - Fax:858-202-1701
Practice Address - Street 1:6540 LUSK BLVD
Practice Address - Street 2:SUITE C-159
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2766
Practice Address - Country:US
Practice Address - Phone:858-202-1777
Practice Address - Fax:858-202-1701
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT19739101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health