Provider Demographics
NPI:1235127572
Name:SANDRA BUNCH WALTON
Entity Type:Organization
Organization Name:SANDRA BUNCH WALTON
Other - Org Name:LIFE QUEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:BUNCH
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, CNS
Authorized Official - Phone:252-758-4554
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126AMOtherBCBS
NC2802084AMedicare ID - Type Unspecified