Provider Demographics
NPI:1790033033
Name:CARROLL, WALKER T (BS)
Entity Type:Individual
Prefix:
First Name:WALKER
Middle Name:T
Last Name:CARROLL
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2128
Mailing Address - Country:US
Mailing Address - Phone:580-920-0909
Mailing Address - Fax:580-931-3119
Practice Address - Street 1:1604 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2128
Practice Address - Country:US
Practice Address - Phone:580-920-0909
Practice Address - Fax:580-931-3119
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health