Provider Demographics
NPI:1407522287
Name:WALTON, MYNGNON DENISE (LAPC, CAMS)
Entity Type:Individual
Prefix:
First Name:MYNGNON
Middle Name:DENISE
Last Name:WALTON
Suffix:
Gender:F
Credentials:LAPC, CAMS
Other - Prefix:
Other - First Name:MYNGNON
Other - Middle Name:DENISE
Other - Last Name:GAUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1129 BRIAR COVE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-3382
Mailing Address - Country:US
Mailing Address - Phone:678-595-0548
Mailing Address - Fax:
Practice Address - Street 1:1129 BRIAR COVE CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-3382
Practice Address - Country:US
Practice Address - Phone:678-595-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional