Basic Information
| Provider Information | |||||||||
| NPI: | 1457652034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | CAMILLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DENTON | ||||||||
| OtherFirstName: | CAMILLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1620 N MAIN ST | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945964653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 N MAIN ST | ||||||||
| Address2: | SUITE #1 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945964653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252866050 | ||||||||
| FaxNumber: | 9259376782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2010 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | Y |
No ID Information.