Provider Demographics
NPI:1235417403
Name:WALTON, ELISE S (CMT, CLT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:S
Last Name:WALTON
Suffix:
Gender:F
Credentials:CMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 HEATHGLEN CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6395
Mailing Address - Country:US
Mailing Address - Phone:757-412-7527
Mailing Address - Fax:757-471-9330
Practice Address - Street 1:522 S INDEPENDENCE BLVD STE 202A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1163
Practice Address - Country:US
Practice Address - Phone:757-412-7527
Practice Address - Fax:757-471-9330
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist