Provider Demographics
NPI:1316420607
Name:WALTHALL, ALEXA (PHD)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29863 SANTA MARGARITA PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3625
Mailing Address - Country:US
Mailing Address - Phone:949-713-3188
Mailing Address - Fax:949-713-3189
Practice Address - Street 1:29863 SANTA MARGARITA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-3625
Practice Address - Country:US
Practice Address - Phone:949-713-3188
Practice Address - Fax:949-713-3189
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21939103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist