Healthcare Provider Details

I. General information

NPI: 1972618163
Provider Name (Legal Business Name): KEITH WALKER C.I.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 6 MEADOW LANE
PINEVILLE LA
71360
US

IV. Provider business mailing address

1717 TULLAMORE ST
ALEXANDRIA LA
71303-5257
US

V. Phone/Fax

Practice location:
  • Phone: 318-484-6889
  • Fax: 318-487-5703
Mailing address:
  • Phone: 318-449-4538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1769
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: