Provider Demographics
NPI:1922169143
Name:BRANCH, WALTER B (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:B
Last Name:BRANCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 STEPHENSON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5929
Mailing Address - Country:US
Mailing Address - Phone:912-352-2992
Mailing Address - Fax:912-352-3447
Practice Address - Street 1:322 STEPHENSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5929
Practice Address - Country:US
Practice Address - Phone:912-352-2992
Practice Address - Fax:912-352-3447
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001610103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00537248BMedicaid
GA68BBCLF GPR1371Medicare ID - Type UnspecifiedMEDICARE ID