Provider Demographics
NPI:1063183754
Name:WALDEN, TAYLOR NICOLE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4629 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-4107
Mailing Address - Country:US
Mailing Address - Phone:850-503-6636
Mailing Address - Fax:850-626-6142
Practice Address - Street 1:4629 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-4107
Practice Address - Country:US
Practice Address - Phone:850-503-6636
Practice Address - Fax:850-626-6132
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-186061106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty