Provider Demographics
NPI:1922069566
Name:SMITH, WALANDA WALKER (PHD)
Entity Type:Individual
Prefix:
First Name:WALANDA
Middle Name:WALKER
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:WALANDA
Other - Middle Name:VIOLET
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18789 N REEMS RD
Mailing Address - Street 2:STE. 260
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-8648
Mailing Address - Country:US
Mailing Address - Phone:623-544-3223
Mailing Address - Fax:623-544-3694
Practice Address - Street 1:18789 N REEMS RD
Practice Address - Street 2:STE. 260
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-8648
Practice Address - Country:US
Practice Address - Phone:623-544-3223
Practice Address - Fax:623-544-3694
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3289103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
107908Medicare ID - Type Unspecified
AZ967515Medicaid