Provider Demographics
NPI:1588792188
Name:MARTIN, WALTER PATRICK (MFT)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:PATRICK
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10650 SCRIPPS RANCH BLVD
Mailing Address - Street 2:STE 131
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131
Mailing Address - Country:US
Mailing Address - Phone:760-498-1053
Mailing Address - Fax:619-924-9931
Practice Address - Street 1:4257 PASO DEL LAGOS
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-4910
Practice Address - Country:US
Practice Address - Phone:760-498-1053
Practice Address - Fax:619-619-9249
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51509106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health