Provider Demographics
NPI:1912398231
Name:WALTZ, R.PERRY (EDS)
Entity Type:Individual
Prefix:
First Name:R.PERRY
Middle Name:
Last Name:WALTZ
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CLAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-1614
Mailing Address - Country:US
Mailing Address - Phone:740-439-4019
Mailing Address - Fax:740-439-0734
Practice Address - Street 1:1300 CLAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-1614
Practice Address - Country:US
Practice Address - Phone:740-439-4019
Practice Address - Fax:740-439-0734
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHKU1027056103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool