Provider Demographics
NPI:1801659289
Name:WALKER, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 46TH AVE SE APT 312
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4853
Mailing Address - Country:US
Mailing Address - Phone:701-400-7498
Mailing Address - Fax:
Practice Address - Street 1:2200 46TH AVE SE APT 312
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4853
Practice Address - Country:US
Practice Address - Phone:701-400-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND103TE1100X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports