Provider Demographics
NPI:1104188069
Name:WALTON, TENISHA
Entity Type:Individual
Prefix:
First Name:TENISHA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 VITRUVIAN WAY
Mailing Address - Street 2:APT 115
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4035
Mailing Address - Country:US
Mailing Address - Phone:617-538-6178
Mailing Address - Fax:
Practice Address - Street 1:3820 VITRUVIAN WAY
Practice Address - Street 2:APT 115
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4035
Practice Address - Country:US
Practice Address - Phone:617-538-6178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2088618225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant