MEDICARE: DR. RANDY N WALTON PH.D.

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	103TC0700X	Clinical Psychologist	0810001644	VA

General Provider Information

NPI Number	:	1417916453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY N WALTON PH.D.

Provider Business Mailing Address
First Line	:	481 MCLAWS CIR
Second Line	:	SUITE 1
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-5645
Country	:	US
Telephone Number	:	757-229-9286
Fax Number	:	757-229-9626

Provider Business Practice Location Address
First Line	:	481 MCLAWS CIR
Second Line	:	SUITE 1
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-5645
Country	:	US
Telephone Number	:	757-229-9286
Fax Number	:	757-229-9626

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

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	01/25/2019

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