Provider Demographics
NPI:1972038842
Name:WALTON, PRISCILLA
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
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 1:4725 CASTLE ROCK CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-4801
Mailing Address - Country:US
Mailing Address - Phone:702-528-1610
Mailing Address - Fax:
Practice Address - Street 1:911 N BUFFALO DR
Practice Address - Street 2:#213
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0379
Practice Address - Country:US
Practice Address - Phone:702-528-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0581101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV145600645Medicare PIN