Provider Demographics
NPI:1174076293
Name:WAITKUS, TALIA (LCSW BCBA)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:WAITKUS
Suffix:
Gender:F
Credentials:LCSW BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 OLD LEEDS LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-3314
Mailing Address - Country:US
Mailing Address - Phone:407-227-7845
Mailing Address - Fax:
Practice Address - Street 1:4236 OLD LEEDS LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35213-3314
Practice Address - Country:US
Practice Address - Phone:407-227-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLSW23067104100000X
AL6192C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker