Provider Demographics
NPI:1205145174
Name:WALD, RAPHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:
Last Name:WALD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 NW 13TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2269
Mailing Address - Country:US
Mailing Address - Phone:561-955-6663
Mailing Address - Fax:561-955-2879
Practice Address - Street 1:800 MEADOWS RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2304
Practice Address - Country:US
Practice Address - Phone:561-955-4600
Practice Address - Fax:833-625-1604
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8167103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEN144ZMedicare PIN