Healthcare Provider Details

I. General information

NPI: 1699338921
Provider Name (Legal Business Name): LAUREN ELIZABETH TILDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 MAR WALT DR STE 2021
FORT WALTON BEACH FL
32547-6756
US

IV. Provider business mailing address

907 MAR WALT DR STE 2021
FORT WALTON BEACH FL
32547-6756
US

V. Phone/Fax

Practice location:
  • Phone: 850-462-4386
  • Fax:
Mailing address:
  • Phone: 850-462-4386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number02475-I
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT3322
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: