Provider Demographics
NPI:1912378811
Name:WALTON, MICHAEL (LCAS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALTON
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-202-5709
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:309 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-3280
Practice Address - Country:US
Practice Address - Phone:102-590-6689
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-18
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20516101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC191237881Medicaid