Healthcare Provider Details

I. General information

NPI: 1861890923
Provider Name (Legal Business Name): MR. LEE WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LEE A WALKER LISW

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 ATHENS ST
CARNESVILLE GA
30521-3669
US

IV. Provider business mailing address

33 ATHENS ST
CARNESVILLE GA
30521-3669
US

V. Phone/Fax

Practice location:
  • Phone: 706-340-7395
  • Fax:
Mailing address:
  • Phone: 706-340-7395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5324
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW001645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: