Provider Demographics
NPI:1386232742
Name:WALD, ANNIE (MA)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:WALD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHAKER LN
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1906
Mailing Address - Country:US
Mailing Address - Phone:978-742-5960
Mailing Address - Fax:
Practice Address - Street 1:150 S WARNER RD STE 130
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2826
Practice Address - Country:US
Practice Address - Phone:484-442-0478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPRE-LICENSED101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health