Provider Demographics
NPI:1790980829
Name:AWALT, ROBERT MITCHELL (PSYD AND LCSW)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MITCHELL
Last Name:AWALT
Suffix:
Gender:M
Credentials:PSYD AND LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4109
Mailing Address - Country:US
Mailing Address - Phone:619-221-6589
Mailing Address - Fax:619-221-6556
Practice Address - Street 1:3420 KENYON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5001
Practice Address - Country:US
Practice Address - Phone:619-221-6550
Practice Address - Fax:619-221-6556
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16566103TA0400X, 103TC1900X, 103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral