Provider Demographics
NPI:1417916453
Name:WALTON, RANDY N (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:N
Last Name:WALTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 MCLAWS CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5645
Mailing Address - Country:US
Mailing Address - Phone:757-229-9286
Mailing Address - Fax:757-229-9626
Practice Address - Street 1:481 MCLAWS CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5645
Practice Address - Country:US
Practice Address - Phone:757-229-9286
Practice Address - Fax:757-229-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001644103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
680000809Medicare ID - Type Unspecified