Provider Demographics
NPI:1346940632
Name:WALTON, LISA MARIA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIA
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 1:11953 ROCHESTER AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2134
Mailing Address - Country:US
Mailing Address - Phone:310-922-0397
Mailing Address - Fax:
Practice Address - Street 1:11500 W OLYMPIC BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1525
Practice Address - Country:US
Practice Address - Phone:424-431-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist