Provider Demographics
NPI:1407104078
Name:WASELKOW, DAVID JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WASELKOW
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20280 N 59TH AVE STE 115-617
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6850
Mailing Address - Country:US
Mailing Address - Phone:602-795-8710
Mailing Address - Fax:602-795-8701
Practice Address - Street 1:725 S DOBSON RD STE 100
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5676
Practice Address - Country:US
Practice Address - Phone:602-795-8700
Practice Address - Fax:602-795-8701
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC17492101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health