Healthcare Provider Details

I. General information

NPI: 1508821893
Provider Name (Legal Business Name): WALTER PETER HUMENICK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 78 BOX 7362
APO AP
96326
JP

IV. Provider business mailing address

PSC 78 BOX 7362
APO AP
96326
JP

V. Phone/Fax

Practice location:
  • Phone: 080348271
  • Fax: 08034271
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-11409
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-10817
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: