Provider Demographics
NPI:1427051861
Name:KNAKE, WALTER PIERCE JR (PHD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:PIERCE
Last Name:KNAKE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:WALTER
Other - Middle Name:P
Other - Last Name:KNAKE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:19801 SUSSEX RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4916
Mailing Address - Country:US
Mailing Address - Phone:216-561-1726
Mailing Address - Fax:216-831-5804
Practice Address - Street 1:3659 S. GREEN RD.
Practice Address - Street 2:SUITE 119
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5715
Practice Address - Country:US
Practice Address - Phone:216-831-0056
Practice Address - Fax:216-831-5804
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538967Medicaid
OHBWC 341493791-00OtherCLINICAL PSYCHOLOGIST
OHMAGELLAN 27059000OtherCLINICAL PSYCHOLOGIST
OHBWC 341493791-00OtherCLINICAL PSYCHOLOGIST
OHR71189Medicare UPIN