Provider Demographics
NPI:1760538581
Name:TOMMIE L. WALTON, III INC.
Entity Type:Organization
Organization Name:TOMMIE L. WALTON, III INC.
Other - Org Name:RECOVERY CAFE/ LARRY WALTON AND ASSOC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:III
Authorized Official - Credentials:LCSW
Authorized Official - Phone:706-369-0970
Mailing Address - Street 1:PO BOX 7392
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7392
Mailing Address - Country:US
Mailing Address - Phone:706-369-0970
Mailing Address - Fax:706-353-1943
Practice Address - Street 1:325 N MILLEDGE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-3805
Practice Address - Country:US
Practice Address - Phone:706-369-0970
Practice Address - Fax:706-353-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000692103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004509000OtherMAGELLAN ID#
GA80BBFGCMedicare UPIN