Provider Demographics
NPI:1396790036
Name:WALDMAN, LARRY FOSTER (PHD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:FOSTER
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 N TATUM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:602-996-8619
Mailing Address - Fax:602-996-7932
Practice Address - Street 1:11020 N TATUM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:602-996-8619
Practice Address - Fax:602-996-7932
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ834103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000BGMMWMedicare ID - Type Unspecified
S11657Medicare UPIN