Healthcare Provider Details

I. General information

NPI: 1902333107
Provider Name (Legal Business Name): KEENAN ALEXANDER WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PHIPPS, ROOM 446 600 NORTH WOLFE STREET
BALTIMORE MD
21287
US

IV. Provider business mailing address

600 NORTH WOLFE ST. PHIPPS, ROOM 446
BALTIMORE MD
21287
US

V. Phone/Fax

Practice location:
  • Phone: 626-840-6216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: