Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | CSAC21416 | NC |
N | 101YM0800X | Mental Health Counselor | A12877 | NC |
N | 101YP1600X | Pastoral Counselor | ||
Y | 101YP2500X | Professional Counselor | A12877 | NC |
NPI | 1013437748 |
---|---|
Provider Name | Tyler Walston |
First Address | Kenly, NC 27542-9497 |
Second Address | Wilson, NC 27896-8040 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2017 |
Last Update Date | 23/06/2017 |