Healthcare Provider Details

I. General information

NPI: 1366075269
Provider Name (Legal Business Name): KAREN ANN WALTON EBNIT CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 KINGSTON CT
MIDLAND MI
48642-3534
US

IV. Provider business mailing address

4614 KINGSTON CT
MIDLAND MI
48642-3534
US

V. Phone/Fax

Practice location:
  • Phone: 989-859-0074
  • Fax:
Mailing address:
  • Phone: 989-859-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101002767
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: