Provider Demographics
NPI:1609093129
Name:WALDERN, ANGELA B (OTR)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:B
Last Name:WALDERN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:B
Other - Last Name:LINDAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3840 HULEN ST
Mailing Address - Street 2:603
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7277
Mailing Address - Country:US
Mailing Address - Phone:817-360-0526
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:603
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-360-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110843225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157484004Medicaid
TX15-7484001Medicaid
TX8TAB75OtherBLUE CROSS BLUE SHIELD