Provider Demographics
NPI:1629178348
Name:WALDO, MATURIN FRYE (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:MATURIN
Middle Name:FRYE
Last Name:WALDO
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0390
Mailing Address - Country:US
Mailing Address - Phone:860-271-4700
Mailing Address - Fax:
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-271-4700
Practice Address - Fax:860-271-4797
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0072361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400021140Medicare PIN