Provider Demographics
NPI:1407946791
Name:WALTON, CHARLES BRIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRIAN
Last Name:WALTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 KIMRY MOOR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1854
Mailing Address - Country:US
Mailing Address - Phone:315-423-3810
Mailing Address - Fax:
Practice Address - Street 1:6834 E GENESEE ST STE C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1021
Practice Address - Country:US
Practice Address - Phone:315-447-3798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO11729-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56423BMedicare ID - Type Unspecified