Provider Demographics
NPI:1023255262
Name:PHILLIPS, WALTER H (MFT)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:H
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:WALLY
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:296 FIRETHORN DR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-5710
Mailing Address - Country:US
Mailing Address - Phone:415-845-0446
Mailing Address - Fax:415-480-2878
Practice Address - Street 1:250 BEL MARIN KEYS BLVD STE C5
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-5708
Practice Address - Country:US
Practice Address - Phone:415-788-4444
Practice Address - Fax:415-480-2878
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT46007106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204377OtherMARRIAGE AND FAMILY THERAPIST LICENSE