Provider Demographics
NPI:1285850180
Name:WALTMAN, DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:WALTMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9002 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6302
Mailing Address - Country:US
Mailing Address - Phone:440-205-1008
Mailing Address - Fax:440-205-1047
Practice Address - Street 1:9002 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6302
Practice Address - Country:US
Practice Address - Phone:440-205-1008
Practice Address - Fax:440-205-1047
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3553103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWACP 17841Medicare PIN