Provider Demographics
NPI:1740140540
Name:BLACKFOX, WALTER DEAN JR
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:DEAN
Last Name:BLACKFOX
Suffix:JR
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 1:5836 FAIRVIEW PL
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2232
Mailing Address - Country:US
Mailing Address - Phone:805-413-5600
Mailing Address - Fax:888-827-2346
Practice Address - Street 1:5836 FAIRVIEW PL
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2232
Practice Address - Country:US
Practice Address - Phone:805-413-5600
Practice Address - Fax:888-827-2346
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator