Healthcare Provider Details

I. General information

NPI: 1073417069
Provider Name (Legal Business Name): SHANELL A WALTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9506 PARADISE PL
RIVERSIDE CA
92508-8008
US

IV. Provider business mailing address

9506 PARADISE PL
RIVERSIDE CA
92508-8008
US

V. Phone/Fax

Practice location:
  • Phone: 323-830-1026
  • Fax:
Mailing address:
  • Phone: 323-830-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: