Provider Demographics
NPI:1003657941
Name:WAITZMAN, PHILIP (LCSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:WAITZMAN
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 1:415 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3100
Mailing Address - Country:US
Mailing Address - Phone:269-408-1688
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3100
Practice Address - Country:US
Practice Address - Phone:269-408-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0250611041C0700X
MI68011183161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical