Provider Demographics
NPI:1265595805
Name:WALDO, ANDREA (MS, LCMHC)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:WALDO
Suffix:
Gender:F
Credentials:MS, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-0846
Mailing Address - Country:US
Mailing Address - Phone:802-363-9515
Mailing Address - Fax:
Practice Address - Street 1:5138 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-6698
Practice Address - Country:US
Practice Address - Phone:802-363-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068-0000331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006797Medicaid