Provider Demographics
NPI:1891493847
Name:WALTON, KAYLA JACKIE BRENYA
Entity Type:Individual
Prefix:
First Name:KAYLA JACKIE
Middle Name:BRENYA
Last Name: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 1:1947 GALILEO CT STE 101
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4882
Mailing Address - Country:US
Mailing Address - Phone:323-387-1712
Mailing Address - Fax:
Practice Address - Street 1:1666 DA VINCI CT
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-4845
Practice Address - Country:US
Practice Address - Phone:323-387-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY9195196106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician