Provider Demographics
NPI:1124242532
Name:WALTON-MOUW, RACHAEL ANN (PT)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:ANN
Last Name:WALTON-MOUW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:ANN
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2324 EASTWAY RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5546
Mailing Address - Country:US
Mailing Address - Phone:404-606-2951
Mailing Address - Fax:
Practice Address - Street 1:1947 BRIARWOOD CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329
Practice Address - Country:US
Practice Address - Phone:404-873-3725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCQPMedicare ID - Type UnspecifiedMEIDCARE PIN
GAQ23287Medicare UPIN