Provider Demographics
NPI:1508089798
Name:WALDEN, EDIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDIE
Middle Name:
Last Name:WALDEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BON AIR SHOPPING CTR # 519
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-3017
Mailing Address - Country:US
Mailing Address - Phone:415-461-4322
Mailing Address - Fax:415-461-4322
Practice Address - Street 1:711 D ST STE 117
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3703
Practice Address - Country:US
Practice Address - Phone:415-461-4322
Practice Address - Fax:415-461-4322
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18112103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical