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General NPI Number Information
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NPI Number | 1679762082
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Entity Type | Individual
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Provider Name | WALTER GILLICAN CHAMBERLAIN JR. M.ED, LPC, BCBA
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Gender | Male
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Dates
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Enumeration Date | 10/22/2007
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 2415 17TH ST
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City | GULFPORT
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State | MS
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Zip | 39501-2906
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Country | US
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Telephone | 228-701-0085
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Fax | 220-701-0054
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Provider Business Mailing Address
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Address Line | 79321 DIAMONDHEAD DR E
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City | DIAMONDHEAD
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State | MS
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Zip | 39525-3544
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Country | US
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Telephone | 601-850-8663
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Fax | 228-701-0054
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-11-9380
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 1548
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License Number State | MS
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