Provider Demographics
NPI:1376178210
Name:MELDRUM, WALTER JAMES (CADC, BS, QSUDP)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JAMES
Last Name:MELDRUM
Suffix:
Gender:M
Credentials:CADC, BS, QSUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1682 E TIME ZONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4500
Mailing Address - Country:US
Mailing Address - Phone:208-351-2765
Mailing Address - Fax:
Practice Address - Street 1:1299 N ORCHARD ST STE 110
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2266
Practice Address - Country:US
Practice Address - Phone:208-672-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)