Healthcare Provider Details

I. General information

NPI: 1114081411
Provider Name (Legal Business Name): LAURETTA WALKER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BOULDER DR
IRONTON MO
63650-9108
US

IV. Provider business mailing address

201 BOULDER DR
IRONTON MO
63650-9108
US

V. Phone/Fax

Practice location:
  • Phone: 573-546-3073
  • Fax: 573-546-3073
Mailing address:
  • Phone: 573-546-3073
  • Fax: 573-546-3073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number00430
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: