Provider Demographics
NPI:1609140722
Name:WALDRON, SEAN PAUL (MSW)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:PAUL
Last Name:WALDRON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 SUMMER WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8258
Mailing Address - Country:US
Mailing Address - Phone:208-522-0175
Mailing Address - Fax:
Practice Address - Street 1:1070 HILINE RD STE 210
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2947
Practice Address - Country:US
Practice Address - Phone:208-478-9081
Practice Address - Fax:208-478-4999
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID31792104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker