Provider Demographics
NPI:1093703324
Name:WALTON, SANDRA BUNCH (LMFT, CNS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:BUNCH
Last Name:WALTON
Suffix:
Gender:F
Credentials:LMFT, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 ALLEN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-0058
Mailing Address - Country:US
Mailing Address - Phone:252-758-4554
Mailing Address - Fax:252-758-5561
Practice Address - Street 1:1990 ALLEN RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-0058
Practice Address - Country:US
Practice Address - Phone:252-758-4554
Practice Address - Fax:252-758-5561
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC153106H00000X
NC0229130-37364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126AMOtherBCBS
NC2802084AMedicare PIN