Provider Demographics
NPI:1356843676
Name:WALK, DEANNA (PCSW)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WALK
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1700
Mailing Address - Country:US
Mailing Address - Phone:801-428-4257
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-428-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WY390200000X
WY13568436761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY390200000X.Medicaid