Provider Demographics
NPI:1295765238
Name:WALDRON, STACY ALICE (PHD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ALICE
Last Name:WALDRON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3704
Mailing Address - Country:US
Mailing Address - Phone:402-481-5991
Mailing Address - Fax:
Practice Address - Street 1:2300 S 16TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3704
Practice Address - Country:US
Practice Address - Phone:402-481-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60016697103TC1900X
UT6291316-2501103TC1900X
NE696103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA1274002Medicare PIN
NE10025725500Medicaid