MEDICARE: GRACIE FAITH WALSTON

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	106S00000X	Behavior Technician		KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518899301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACIE FAITH WALSTON

Provider Business Mailing Address
First Line	:	85 RADIO STATION RD
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-8166
Country	:	US
Telephone Number	:	270-692-7127
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 RADIO STATION RD
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-8166
Country	:	US
Telephone Number	:	270-692-7127
Fax Number	:

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

Provider Enumeration Date	:	06/03/2026
Last Update Date	:	06/03/2026

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Directions to “ GRACIE FAITH WALSTON ” Practice Location

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