Provider Demographics
NPI:1619418886
Name:WALKER, VANCE A
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:A
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E OAKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-3547
Mailing Address - Country:US
Mailing Address - Phone:850-689-1234
Mailing Address - Fax:
Practice Address - Street 1:259 E OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3547
Practice Address - Country:US
Practice Address - Phone:850-689-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13742101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor