Healthcare Provider Details

I. General information

NPI: 1841803178
Provider Name (Legal Business Name): MICHAELLA WALTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 BOULEVARD ST STE C
GREENSBORO NC
27407-4579
US

IV. Provider business mailing address

2003 BOULEVARD ST STE C
GREENSBORO NC
27407-4579
US

V. Phone/Fax

Practice location:
  • Phone: 336-339-6747
  • Fax:
Mailing address:
  • Phone: 336-339-6747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-26733
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP015172
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: