Provider Demographics
NPI:1083620660
Name:WALKER, EDWARD MARTIN (PHD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARTIN
Last Name:WALKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 CHESTNUT RIDGE RD FL 2
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6314
Mailing Address - Country:US
Mailing Address - Phone:917-679-6764
Mailing Address - Fax:
Practice Address - Street 1:817 CHESTNUT RIDGE RD FL 2
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-6314
Practice Address - Country:US
Practice Address - Phone:917-679-6764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12624103TC0700X
NY012624-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01631167Medicaid
NYV0247Medicare PIN