Provider Demographics
NPI:1053481069
Name:WALKER, CLARENCE WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:WILLIAM
Last Name:WALKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:C. WILLIAM
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:128 PINE ST., NW
Mailing Address - Street 2:C. WILLIAM WALKER, PH.D.
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273
Mailing Address - Country:US
Mailing Address - Phone:320-354-4489
Mailing Address - Fax:320-354-4490
Practice Address - Street 1:17 ASH STREET, N.E
Practice Address - Street 2:POST OFFICE BOX 92
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273
Practice Address - Country:US
Practice Address - Phone:320-354-4489
Practice Address - Fax:320-354-4490
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNC1083103T00000X
MNLP0321103T00000X
MNLICSW06609104100000X
MNLP0123103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN843748300Medicaid
MN80000114Medicare PIN
MN843748300Medicaid