Provider Demographics
NPI:1467679993
Name:WALDMAN, KENNETH MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:WALDMAN
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 1:11340 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 358
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1608
Mailing Address - Country:US
Mailing Address - Phone:310-473-1505
Mailing Address - Fax:310-455-3783
Practice Address - Street 1:11340 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 358
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1608
Practice Address - Country:US
Practice Address - Phone:310-473-1505
Practice Address - Fax:310-455-3783
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16335103T00000X, 103TC0700X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis