Healthcare Provider Details

I. General information

NPI: 1093329385
Provider Name (Legal Business Name): EBONY GLYNN WALKER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 POPLAR DR
PETERSBURG VA
23805-9367
US

IV. Provider business mailing address

9482 W BRIGHTWAY CIR
HENRICO VA
23294-5564
US

V. Phone/Fax

Practice location:
  • Phone: 804-733-6874
  • Fax:
Mailing address:
  • Phone: 804-937-5254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701009893
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: