MEDICARE: GRACE WALTON

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1417351917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE WALTON

Provider Business Mailing Address
First Line	:	61 HIGH SERVICE AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02911-3410
Country	:	US
Telephone Number	:	530-401-1631
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 HIGH SERVICE AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02911-3410
Country	:	US
Telephone Number	:	530-401-1631
Fax Number	:

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

Provider Enumeration Date	:	10/14/2014
Last Update Date	:	10/14/2014

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Directions to “ GRACE WALTON ” Practice Location

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