Provider Demographics
NPI:1174076293
Name:WAITKUS, TALIA (BCBA LCSW)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:WAITKUS
Suffix:
Gender:F
Credentials:BCBA LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 LOUISIANA AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2352
Mailing Address - Country:US
Mailing Address - Phone:407-225-8557
Mailing Address - Fax:
Practice Address - Street 1:1177 LOUISIANA AVE STE 215
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2352
Practice Address - Country:US
Practice Address - Phone:407-225-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLSW23067104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst