Provider Demographics
NPI:1467542878
Name:WOLDT, ANSEL L (EDD)
Entity Type:Individual
Prefix:DR
First Name:ANSEL
Middle Name:L
Last Name:WOLDT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 770502
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-0027
Mailing Address - Country:US
Mailing Address - Phone:216-251-0505
Mailing Address - Fax:216-251-0508
Practice Address - Street 1:511 BERYL DR
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4403
Practice Address - Country:US
Practice Address - Phone:330-673-8729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH982103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0948078Medicaid
OH0948078Medicaid