Provider Demographics
NPI:1639995137
Name:WAULDRON, ALYSSA (LMSW)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WAULDRON
Suffix:
Gender:U
Credentials:LMSW
Other - Prefix:
Other - First Name:AL
Other - Middle Name:
Other - Last Name:WAULDRON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:735 BUSHWICK AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2555
Mailing Address - Country:US
Mailing Address - Phone:989-289-7239
Mailing Address - Fax:
Practice Address - Street 1:3300 WASHTENAW AVE STE 260
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5184
Practice Address - Country:US
Practice Address - Phone:734-277-7565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011189801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical