Provider Demographics
NPI:1285887968
Name:WALKER, RANDY (FAODP)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:MR
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2081 W. GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1105
Mailing Address - Country:US
Mailing Address - Phone:313-895-0500
Mailing Address - Fax:313-895-9503
Practice Address - Street 1:2081 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:313-895-0500
Practice Address - Fax:313-895-9503
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803044972101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional