Basic Information
| Provider Information | |||||||||
| NPI: | 1972689867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | WAGONER | ||||||||
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| Credential: | OT/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 STONE HOUSE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400049028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023501151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 875 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400042529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023496961 | ||||||||
| FaxNumber: | 5023481789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | KY-R2658 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.