Provider Demographics
NPI:1811668320
Name:WALLE, MONICA
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:
Last Name:WALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 LAVON LN
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-1740
Mailing Address - Country:US
Mailing Address - Phone:209-480-6456
Mailing Address - Fax:
Practice Address - Street 1:1405 11TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0748
Practice Address - Country:US
Practice Address - Phone:209-284-0070
Practice Address - Fax:209-284-0971
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health