Provider Demographics
NPI:1972689867
Name:WALTON, STEPHANIE WAGONER (OT/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:WAGONER
Last Name:WALTON
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 STONE HOUSE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9028
Mailing Address - Country:US
Mailing Address - Phone:502-350-1151
Mailing Address - Fax:
Practice Address - Street 1:875 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2529
Practice Address - Country:US
Practice Address - Phone:502-349-6961
Practice Address - Fax:502-348-1789
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2658225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist