Provider Demographics
NPI:1184303406
Name:WALTON, RACQUEL
Entity type:Individual
Prefix:
First Name:RACQUEL
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 1:4896 SOURWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7030
Mailing Address - Country:US
Mailing Address - Phone:614-446-0311
Mailing Address - Fax:
Practice Address - Street 1:4896 SOURWOOD LN
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7030
Practice Address - Country:US
Practice Address - Phone:614-446-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
OH000000000202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool