Provider Demographics
NPI:1518773142
Name:WALKER, THEODORE LAURENCE (PRSS)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:LAURENCE
Last Name:WALKER
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2741
Mailing Address - Country:US
Mailing Address - Phone:330-577-4099
Mailing Address - Fax:844-274-3002
Practice Address - Street 1:223 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2741
Practice Address - Country:US
Practice Address - Phone:330-577-4099
Practice Address - Fax:844-274-3002
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005855175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist