Provider Demographics
NPI:1720213374
Name:WALTON ELLIS, KEASHA T
Entity Type:Individual
Prefix:
First Name:KEASHA
Middle Name:T
Last Name:WALTON ELLIS
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 1:4343 WILLIAMSBOURGH DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2006
Mailing Address - Country:US
Mailing Address - Phone:916-395-3552
Mailing Address - Fax:916-473-5766
Practice Address - Street 1:5523 34TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-4725
Practice Address - Country:US
Practice Address - Phone:916-452-3601
Practice Address - Fax:916-453-2829
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health