Provider Demographics
NPI:1508409897
Name:GOODMAN-WALKER, TIANA TYLEI
Entity Type:Individual
Prefix:
First Name:TIANA
Middle Name:TYLEI
Last Name:GOODMAN-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 1:1825 SAINT JULIAN PL APT 9B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2483
Mailing Address - Country:US
Mailing Address - Phone:803-586-3035
Mailing Address - Fax:
Practice Address - Street 1:1825 SAINT JULIAN PL APT 9B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2483
Practice Address - Country:US
Practice Address - Phone:803-586-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRC617841744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management