1356329452 NPI number — MR. TOMMIE LAURICE WALTON III CSW

Table of content: MR. TOMMIE LAURICE WALTON III CSW (NPI 1356329452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356329452 NPI number — MR. TOMMIE LAURICE WALTON III CSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTON
Provider First Name:
TOMMIE
Provider Middle Name:
LAURICE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
CSW
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:
1356329452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7392
Provider Second Line Business Mailing Address:
188 S MILLEDGE AVE
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-369-0970
Provider Business Mailing Address Fax Number:
706-553-1943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 S MILLEDGE AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-369-0970
Provider Business Practice Location Address Fax Number:
706-353-1943
Provider Enumeration Date:
01/09/2006

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: 104100000X , with the licence number:  LCSW 499 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 000692 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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