Healthcare Provider Details

I. General information

NPI: 1205390838
Provider Name (Legal Business Name): EBONY OPHELIA WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8856 GREENBACK LN
ORANGEVALE CA
95662-4019
US

IV. Provider business mailing address

169 W 5TH ST
STOCKTON CA
95206-2603
US

V. Phone/Fax

Practice location:
  • Phone: 916-956-7979
  • Fax:
Mailing address:
  • Phone: 415-504-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-75322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: