Provider Demographics
NPI:1053590109
Name:WALKER, EBONIE L (LCSW)
Entity type:Individual
Prefix:MRS
First Name:EBONIE
Middle Name:L
Last Name:WALKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:EBONIE
Other - Middle Name:L
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 13296
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-0296
Mailing Address - Country:US
Mailing Address - Phone:757-714-1838
Mailing Address - Fax:757-321-6269
Practice Address - Street 1:4605 PEMBROKE LAKE CIR STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6436
Practice Address - Country:US
Practice Address - Phone:757-395-7237
Practice Address - Fax:757-321-6269
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2009-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040064511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2659993OtherCIGNA BEHAVIORAL
VA000398195OtherUNITED BEHAVIORAL HEALTH
VASC0001119Medicare PIN
VA2659993OtherCIGNA BEHAVIORAL