Provider Demographics
NPI:1285281188
Name:WALKER, DEMETRIOUS
Entity type:Individual
Prefix:
First Name:DEMETRIOUS
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-1175
Mailing Address - Country:US
Mailing Address - Phone:708-541-9785
Mailing Address - Fax:
Practice Address - Street 1:2430 ATHENS RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1954
Practice Address - Country:US
Practice Address - Phone:708-541-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-25
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness