Healthcare Provider Details

I. General information

NPI: 1255076469
Provider Name (Legal Business Name): MR. MARVIN WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 40TH ST
OAKLAND CA
94609-2633
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-613-0330
  • Fax:
Mailing address:
  • Phone: 510-613-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: