=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518358308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY MARQUIS WALTON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2015
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1445 WOODMONT LN NW STE 3703
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-826-9390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 PEBBLE ST
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30038-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-224-9104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW005383
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------