Healthcare Provider Details

I. General information

NPI: 1992195176
Provider Name (Legal Business Name): ANDREA WALTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 CLINTON AVE N
ROCHESTER NY
14604-1455
US

IV. Provider business mailing address

476 OXFORD ST
ROCHESTER NY
14607-3244
US

V. Phone/Fax

Practice location:
  • Phone: 585-546-7220
  • Fax: 585-325-3867
Mailing address:
  • Phone: 585-546-7220
  • Fax: 585-325-3867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number094150
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: