Provider Demographics
NPI:1750460580
Name:WALDO, DIANE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:WALDO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WASHINGTON PL
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-3258
Mailing Address - Country:US
Mailing Address - Phone:781-843-2232
Mailing Address - Fax:781-274-8453
Practice Address - Street 1:8 WASHINGTON PL
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-3258
Practice Address - Country:US
Practice Address - Phone:781-843-2232
Practice Address - Fax:781-274-8453
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1061251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3981OtherBLUECROSS/BLUESHIELD