Provider Demographics
NPI:1477201671
Name:WALDER, SHABRANDIA MARY
Entity Type:Individual
Prefix:
First Name:SHABRANDIA
Middle Name:MARY
Last Name:WALDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 SPRINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-1430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1628 SPRINGFIELD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-1430
Practice Address - Country:US
Practice Address - Phone:937-802-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411413Medicaid