Provider Demographics
NPI:1245755107
Name:WALKER, PHOENIX LYN BLACK (LADC)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:LYN BLACK
Last Name:WALKER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:LYNN
Other - Last Name:MULLIS-DWORNIKOWSK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-730-2367
Practice Address - Street 1:1401 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2407
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-730-2367
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300519101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)