Provider Demographics
NPI:1598440919
Name:WALKER, DEMETRICE LATRICE
Entity Type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:LATRICE
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 1:405 W MANCHESTER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1196
Mailing Address - Country:US
Mailing Address - Phone:310-672-3820
Mailing Address - Fax:
Practice Address - Street 1:405 W MANCHESTER BLVD STE A
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1196
Practice Address - Country:US
Practice Address - Phone:310-672-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health