Provider Demographics
NPI:1821209180
Name:WALD, MICHAEL ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:WALD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1889 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-3055
Mailing Address - Country:US
Mailing Address - Phone:914-834-2545
Mailing Address - Fax:914-834-5925
Practice Address - Street 1:1889 PALMER AVE
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-3055
Practice Address - Country:US
Practice Address - Phone:914-834-2545
Practice Address - Fax:914-834-5925
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7152103TC0700X
CT1486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV24413Medicare ID - Type Unspecified
NYV24411Medicare ID - Type Unspecified