Provider Demographics
NPI:1073627725
Name:WALDMAN, KENNETH R (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:R
Other - Last Name:WALDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1428 CRYSTAL LAKE CIR E
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-2567
Mailing Address - Country:US
Mailing Address - Phone:713-670-6626
Mailing Address - Fax:713-774-3223
Practice Address - Street 1:8303 SW FWY STE 330
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1601
Practice Address - Country:US
Practice Address - Phone:713-774-2122
Practice Address - Fax:713-774-3223
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1460 TX103TC1900X
TX331106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742043057OtherEMPLOYER ID