MEDICARE: ELISE S WALTON CMT, CLT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	0019006593	VA

General Provider Information

NPI Number	:	1235417403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISE S WALTON CMT, CLT

Provider Business Mailing Address
First Line	:	5245 HEATHGLEN CIR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-6395
Country	:	US
Telephone Number	:	757-412-7527
Fax Number	:	757-471-9330

Provider Business Practice Location Address
First Line	:	522 S INDEPENDENCE BLVD STE 202A
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1163
Country	:	US
Telephone Number	:	757-412-7527
Fax Number	:	757-471-9330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	10/21/2014

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