Healthcare Provider Details

I. General information

NPI: 1215622881
Provider Name (Legal Business Name): TYLER WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4703 NW 53RD AVE STE A2
GAINESVILLE FL
32653-3403
US

IV. Provider business mailing address

4703 NW 53RD AVE STE A2
GAINESVILLE FL
32653-3403
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-6131
  • Fax:
Mailing address:
  • Phone: 352-332-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21912
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: