Healthcare Provider Details

I. General information

NPI: 1285379651
Provider Name (Legal Business Name): MONA MAXINE WALKER BEHAVIOR TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 05/01/2022
Certification Date: 05/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 REDWOOD WAY
PETALUMA CA
94954-1107
US

IV. Provider business mailing address

1301 REDWOOD WAY
PETALUMA CA
94954-1107
US

V. Phone/Fax

Practice location:
  • Phone: 707-806-9921
  • Fax:
Mailing address:
  • Phone: 707-806-9921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: