Provider Demographics
NPI:1235694191
Name:JOAN S WALDROUP, LCSW, PLLC
Entity Type:Organization
Organization Name:JOAN S WALDROUP, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALDROUP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:228-860-0506
Mailing Address - Street 1:PO BOX 7475
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 43RD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2545
Practice Address - Country:US
Practice Address - Phone:228-234-9460
Practice Address - Fax:228-241-0326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty