Provider Demographics
NPI:1912550864
Name:WALTON, AMY (COTA)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:BARODA
Mailing Address - State:MI
Mailing Address - Zip Code:49101-0116
Mailing Address - Country:US
Mailing Address - Phone:269-876-2366
Mailing Address - Fax:
Practice Address - Street 1:288 PEACE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9562
Practice Address - Country:US
Practice Address - Phone:269-556-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202004464224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant