Provider Demographics
NPI:1679762082
Name:CHAMBERLAIN, WALTER GILLICAN JR (MED, LPC, BCBA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:GILLICAN
Last Name:CHAMBERLAIN
Suffix:JR
Gender:M
Credentials:MED, LPC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:79321 DIAMONDHEAD DR E
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3544
Mailing Address - Country:US
Mailing Address - Phone:601-850-8663
Mailing Address - Fax:228-701-0054
Practice Address - Street 1:2415 17TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2906
Practice Address - Country:US
Practice Address - Phone:228-701-0085
Practice Address - Fax:220-701-0054
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-9380103K00000X
MS1548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst