Provider Demographics
NPI:1689213761
Name:WALDO, JUSTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WALDO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4051 WINNIPEG WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-4631
Mailing Address - Country:US
Mailing Address - Phone:859-457-1716
Mailing Address - Fax:
Practice Address - Street 1:LEXINGTON VA MEDICAL CENTER
Practice Address - Street 2:1101 VETERAN'S DRIVE
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical