Provider Demographics
NPI:1356521942
Name:WALLER, MARK RICHARD (PHD, MFT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:WALLER
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 W MORTON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3185
Mailing Address - Country:US
Mailing Address - Phone:888-401-6275
Mailing Address - Fax:888-401-6275
Practice Address - Street 1:851 W MORTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3185
Practice Address - Country:US
Practice Address - Phone:888-401-6275
Practice Address - Fax:888-401-6275
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36233106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36233OtherSTATE LICENSE NUMBER