Provider Demographics
NPI:1376234435
Name:WALKER, HAVANNAH FAY (AAC CG61359168)
Entity Type:Individual
Prefix:
First Name:HAVANNAH
Middle Name:FAY
Last Name:WALKER
Suffix:
Gender:F
Credentials:AAC CG61359168
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 FERGUSON ST SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6143
Mailing Address - Country:US
Mailing Address - Phone:360-943-1907
Mailing Address - Fax:
Practice Address - Street 1:3285 FERGUSON ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6143
Practice Address - Country:US
Practice Address - Phone:360-943-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61359168101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health