MEDICARE: TANESHA DANIELLE WALKER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC009713	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC009713	OTHER	GA	STATE BOARD OF COUNSELORS

General Provider Information

NPI Number	:	1568960268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANESHA DANIELLE WALKER LPC

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30061-0158
Country	:	US
Telephone Number	:	773-263-6533
Fax Number	:	470-533-1545

Provider Business Practice Location Address
First Line	:	55 ATLANTA ST SE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1977
Country	:	US
Telephone Number	:	470-238-9475
Fax Number	:	470-533-1545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2018
Last Update Date	:	12/01/2020

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