Provider Demographics
NPI:1679022768
Name:SMITH-WALTON, ROSLYN MARIE
Entity Type:Individual
Prefix:
First Name:ROSLYN
Middle Name:MARIE
Last Name:SMITH-WALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3954 E HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-4508
Mailing Address - Country:US
Mailing Address - Phone:559-226-5563
Mailing Address - Fax:
Practice Address - Street 1:4411 N CEDAR AVE STE 108
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2538
Practice Address - Country:US
Practice Address - Phone:559-248-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10AGMedicaid