Provider Demographics
NPI:1124024005
Name:WALDBAUM, JEWELL K (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEWELL
Middle Name:K
Last Name:WALDBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HAWK ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6104
Mailing Address - Country:US
Mailing Address - Phone:845-356-6329
Mailing Address - Fax:845-425-0144
Practice Address - Street 1:12 HAWK ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-6104
Practice Address - Country:US
Practice Address - Phone:845-356-6329
Practice Address - Fax:845-425-0144
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3934103TC0700X, 103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
0081767OtherGHI IDENTIFICATION NUMBER
NY3934OtherNEW YORK STATE LICENSE
V22991Medicare ID - Type UnspecifiedMEDICARE NUMBER