MEDICARE: HAILEY WOLTERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720795438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAILEY WOLTERS

Provider Business Mailing Address
First Line	:	6789 SOUTHPOINT PKWY STE 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8206
Country	:	US
Telephone Number	:	240-808-1411
Fax Number	:

Provider Business Practice Location Address
First Line	:	6789 SOUTHPOINT PKWY STE 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8206
Country	:	US
Telephone Number	:	904-556-7330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	11/02/2022

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Directions to “ HAILEY WOLTERS ” Practice Location

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