Provider Demographics
NPI:1881857811
Name:WALTON, KEITH (FAODP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WALTON
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3274
Mailing Address - Country:US
Mailing Address - Phone:313-236-0077
Mailing Address - Fax:313-883-0442
Practice Address - Street 1:91 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3274
Practice Address - Country:US
Practice Address - Phone:313-236-0077
Practice Address - Fax:313-883-0442
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820317101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor