Provider Demographics
NPI:1588932248
Name:WALKER, DESIRAE PEROUZ (CADC-CAS)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:PEROUZ
Last Name:WALKER
Suffix:
Gender:F
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2496
Mailing Address - Country:US
Mailing Address - Phone:650-430-9867
Mailing Address - Fax:650-355-8780
Practice Address - Street 1:310 HARBOR BLVD BLDG E
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-802-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1099161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARI-M1104291258OtherREGISTERED ADDICTION SPECIALIST INTERN (RASI)
CAASW-109916OtherBOARD OF BEHAVIORAL SCIENCES
CAC05591518OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS