Provider Demographics
NPI:1407593379
Name:WALKER, SAMANTHA AYANNA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:AYANNA
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3017
Mailing Address - Country:US
Mailing Address - Phone:626-974-8123
Mailing Address - Fax:626-974-8198
Practice Address - Street 1:1360 S ANAHEIM BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6205
Practice Address - Country:US
Practice Address - Phone:714-948-7641
Practice Address - Fax:714-689-1381
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116168104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty