Provider Demographics
NPI:1700109865
Name:WALNUM, ROXY RAE (MA, RAS)
Entity Type:Individual
Prefix:
First Name:ROXY
Middle Name:RAE
Last Name:WALNUM
Suffix:
Gender:F
Credentials:MA, RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3776 CARVEACRE RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-4429
Mailing Address - Country:US
Mailing Address - Phone:619-972-8554
Mailing Address - Fax:619-266-7512
Practice Address - Street 1:3940 HOME AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5952
Practice Address - Country:US
Practice Address - Phone:619-262-8000
Practice Address - Fax:619-266-7512
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)