Provider Demographics
NPI:1700374618
Name:WALKER, TELECIA (LMT, CPC, MMP)
Entity Type:Individual
Prefix:MRS
First Name:TELECIA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:LMT, CPC, MMP
Other - Prefix:MRS
Other - First Name:TELECIA
Other - Middle Name:BOUTWELL
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT, CPC, MMP
Mailing Address - Street 1:1720 W FAIRFIELD DR STE 302
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1057
Mailing Address - Country:US
Mailing Address - Phone:850-207-7599
Mailing Address - Fax:850-771-2352
Practice Address - Street 1:1720 W FAIRFIELD DR STE 302
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1057
Practice Address - Country:US
Practice Address - Phone:850-207-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05790225700000X
FLMA90478225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist