Provider Demographics
NPI:1528507274
Name:WALKER, KEITH (CADC II)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2954
Mailing Address - Country:US
Mailing Address - Phone:541-805-0252
Mailing Address - Fax:
Practice Address - Street 1:2107 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2954
Practice Address - Country:US
Practice Address - Phone:541-805-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10-06-71101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)