Provider Demographics
NPI:1295821346
Name:WALDEN, BETHANY LEE (AUD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:LEE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHUMAN BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8123
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:21216 OLEAN BLVD STE 4
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6722
Practice Address - Country:US
Practice Address - Phone:941-766-8886
Practice Address - Fax:941-766-8804
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY211231H00000X, 237600000X, 231HA2400X, 231HA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL204102500OtherU.S. DEPT OF LABOR
FLS0808OtherBLUE CROSS/BLUE SHIELD
FL600341900Medicaid
FL2667047OtherAETNA
FL640004249OtherR.R. MEDICARE
FL7139291OtherAETNA
FL600341900Medicaid