Provider Demographics
NPI:1184081853
Name:WALKER, BREANNA M
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:M
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39121-0073
Mailing Address - Country:US
Mailing Address - Phone:702-308-7682
Mailing Address - Fax:318-414-3067
Practice Address - Street 1:4907 HIGHWAY 84 W
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3579
Practice Address - Country:US
Practice Address - Phone:318-414-3065
Practice Address - Fax:318-414-3067
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)