Provider Demographics
NPI:1376042101
Name:WALTON, MIKAYLA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3810
Mailing Address - Country:US
Mailing Address - Phone:631-889-5997
Mailing Address - Fax:
Practice Address - Street 1:245 NEWTOWN RD STE 102
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4317
Practice Address - Country:US
Practice Address - Phone:516-802-2518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist