Healthcare Provider Details

I. General information

NPI: 1093703324
Provider Name (Legal Business Name): SANDRA BUNCH WALTON LMFT, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 ALLEN RD SUITE B
GREENVILLE NC
27834-0058
US

IV. Provider business mailing address

1990 ALLEN RD SUITE B
GREENVILLE NC
27834-0058
US

V. Phone/Fax

Practice location:
  • Phone: 252-758-4554
  • Fax: 252-758-5561
Mailing address:
  • Phone: 252-758-4554
  • Fax: 252-758-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number153
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number0229130-37
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: