Provider Demographics
NPI:1568964278
Name:SOUTH WALTON ACADEMY, INC.
Entity Type:Organization
Organization Name:SOUTH WALTON ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CALLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MIDDLEBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DT
Authorized Official - Phone:850-213-4595
Mailing Address - Street 1:305 MACK BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7199
Mailing Address - Country:US
Mailing Address - Phone:850-213-4595
Mailing Address - Fax:850-213-4596
Practice Address - Street 1:305 MACK BAYOU RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7199
Practice Address - Country:US
Practice Address - Phone:850-213-4595
Practice Address - Fax:850-213-4596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1255535597Medicaid