Provider Demographics
NPI:1164094116
Name:WALTON, DANIEL RAY (COTA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAY
Last Name:WALTON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S DIVISION ST APT 3
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1881
Mailing Address - Country:US
Mailing Address - Phone:618-318-7193
Mailing Address - Fax:
Practice Address - Street 1:310 S DIVISION ST APT 3
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1881
Practice Address - Country:US
Practice Address - Phone:618-318-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-10
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005498224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant