Healthcare Provider Details

I. General information

NPI: 1205790748
Provider Name (Legal Business Name): TAYAH LYNNE WALDERA E.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N. CAPITAL ST.
MITCHELL SD
57301
US

IV. Provider business mailing address

1420 W UNIVERSITY AVE
MITCHELL SD
57301
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-7502
  • Fax: 605-995-3084
Mailing address:
  • Phone: 605-995-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number92065
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: