Provider Demographics
NPI:1598870834
Name:WALDRON, KENNETH H (PH D)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:WALDRON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 EVERGREEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:WI
Mailing Address - Zip Code:53523
Mailing Address - Country:US
Mailing Address - Phone:608-423-3707
Mailing Address - Fax:
Practice Address - Street 1:6702 STONEFIELD ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562
Practice Address - Country:US
Practice Address - Phone:608-836-5529
Practice Address - Fax:608-836-8059
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1774054103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39104500Medicaid