1679762082 NPI number — MR. WALTER GILLICAN CHAMBERLAIN JR. M.ED, LPC, BCBA

Table of content: MR. WALTER GILLICAN CHAMBERLAIN JR. M.ED, LPC, BCBA (NPI 1679762082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679762082 NPI number — MR. WALTER GILLICAN CHAMBERLAIN JR. M.ED, LPC, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAMBERLAIN
Provider First Name:
WALTER
Provider Middle Name:
GILLICAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.ED, LPC, BCBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679762082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79321 DIAMONDHEAD DR E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIAMONDHEAD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39525-3544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-850-8663
Provider Business Mailing Address Fax Number:
228-701-0054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2415 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-701-0085
Provider Business Practice Location Address Fax Number:
220-701-0054
Provider Enumeration Date:
10/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-11-9380 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 1548 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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