Provider Demographics
NPI:1679736250
Name:WOLTER, DAVID JOHN (MA MFT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:WOLTER
Suffix:
Gender:M
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CLOVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1115
Mailing Address - Country:US
Mailing Address - Phone:559-545-7087
Mailing Address - Fax:559-324-6565
Practice Address - Street 1:264 CLOVIS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1115
Practice Address - Country:US
Practice Address - Phone:559-545-7087
Practice Address - Fax:559-324-6565
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49749106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC49749OtherBBS