Healthcare Provider Details

I. General information

NPI: 1720393556
Provider Name (Legal Business Name): KOURTNI WALTON MS,OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KOURTNI DAMES

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 NW SHIRLEY CT
PORT SAINT LUCIE FL
34986-3596
US

IV. Provider business mailing address

315 NW SHIRLEY CT
PORT SAINT LUCIE FL
34986-3596
US

V. Phone/Fax

Practice location:
  • Phone: 954-465-4467
  • Fax:
Mailing address:
  • Phone: 954-465-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 11861
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: