Provider Demographics
NPI:1376703025
Name:WALKER, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-1309
Mailing Address - Country:US
Mailing Address - Phone:907-772-3332
Mailing Address - Fax:
Practice Address - Street 1:201 NORTH NORDIC DRIVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-1309
Practice Address - Country:US
Practice Address - Phone:907-772-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH1413Medicaid