Provider Demographics
NPI:1609953173
Name:WALTON, WALTER GREGORY (PHD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:GREGORY
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:PO BOX 1630
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-1630
Mailing Address - Country:US
Mailing Address - Phone:910-295-6007
Mailing Address - Fax:910-215-0179
Practice Address - Street 1:289 OLMSTED BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8729
Practice Address - Country:US
Practice Address - Phone:910-295-6007
Practice Address - Fax:910-215-0179
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04816OtherBCBS PIN
NC6000811Medicaid
NC2812948CMedicare PIN