Provider Demographics
NPI:1336369818
Name:WALDEN, ELDA JANNAE (MS)
Entity Type:Individual
Prefix:MRS
First Name:ELDA
Middle Name:JANNAE
Last Name:WALDEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 TYSON AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3315
Mailing Address - Country:US
Mailing Address - Phone:352-425-5896
Mailing Address - Fax:
Practice Address - Street 1:589 TYSON AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3315
Practice Address - Country:US
Practice Address - Phone:352-425-5896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health