Provider Demographics
NPI:1417599531
Name:WALKER, BERNICE L
Entity Type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:L
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 BRACKNELL FOREST TRL
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5706
Mailing Address - Country:US
Mailing Address - Phone:352-434-8454
Mailing Address - Fax:
Practice Address - Street 1:2449 BRACKNELL FOREST TRL
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5706
Practice Address - Country:US
Practice Address - Phone:352-434-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13351135ZMedicaid