Provider Demographics
NPI:1457365447
Name:WALDROUP, JOAN S (LCSW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:S
Last Name:WALDROUP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:T
Other - Last Name:STALNAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 7475
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 43RD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2545
Practice Address - Country:US
Practice Address - Phone:228-234-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC63191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01535581Medicaid
MS$$$$$$$$$AOtherBCBS
MS800000318Medicare PIN