Provider Demographics
NPI:1548048036
Name:WALTON, BANNAH BROOKE
Entity type:Individual
Prefix:
First Name:BANNAH
Middle Name:BROOKE
Last Name:WALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5726 ADICKS CT
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-9487
Mailing Address - Country:US
Mailing Address - Phone:803-579-6201
Mailing Address - Fax:
Practice Address - Street 1:1547 CHERRY RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2616
Practice Address - Country:US
Practice Address - Phone:803-792-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician