Provider Demographics
NPI:1104418318
Name:WALTON, DERREKA J (MSE LPC)
Entity type:Individual
Prefix:
First Name:DERREKA
Middle Name:J
Last Name:WALTON
Suffix:
Gender:F
Credentials:MSE LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 VALLEY RD STE 13
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1012
Mailing Address - Country:US
Mailing Address - Phone:920-872-7292
Mailing Address - Fax:920-872-7066
Practice Address - Street 1:806 VALLEY RD STE 13
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1012
Practice Address - Country:US
Practice Address - Phone:920-872-7292
Practice Address - Fax:920-872-7066
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4757-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health