Provider Demographics
NPI:1356329452
Name:WALTON, TOMMIE LAURICE III (CSW)
Entity Type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:LAURICE
Last Name:WALTON
Suffix:III
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7392
Mailing Address - Street 2:188 S MILLEDGE AVE
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604
Mailing Address - Country:US
Mailing Address - Phone:706-369-0970
Mailing Address - Fax:706-553-1943
Practice Address - Street 1:188 S MILLEDGE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605
Practice Address - Country:US
Practice Address - Phone:706-369-0970
Practice Address - Fax:706-353-1943
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW 499104100000X
GA000692104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBFGCMedicare ID - Type Unspecified