Provider Demographics
NPI:1245379940
Name:WAULDRON, JOSEPH GERARD (MSW, LMSW, CAC-1,ETC)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:GERARD
Last Name:WAULDRON
Suffix:
Gender:M
Credentials:MSW, LMSW, CAC-1,ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3795
Mailing Address - Country:US
Mailing Address - Phone:586-274-0200
Mailing Address - Fax:586-274-0228
Practice Address - Street 1:3701 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-3795
Practice Address - Country:US
Practice Address - Phone:586-274-0200
Practice Address - Fax:586-274-0228
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010206431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical