Basic Information
| Provider Information | |||||||||
| NPI: | 1487200416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | LAKESHA | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3942 CUTTY SARK RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLE RIVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212202332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434211723 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 RESEARCH BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208503215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772212981 | ||||||||
| FaxNumber: | 3016575651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2019 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | A02058 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.