Provider Demographics
NPI:1649352733
Name:WALD, MIRIAM S
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:S
Last Name:WALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5062 MOROCCO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3605
Mailing Address - Country:US
Mailing Address - Phone:707-538-7726
Mailing Address - Fax:
Practice Address - Street 1:523 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL104130OtherBLUE CROSS BLUE SHIELD
CA680006644OtherRAIL ROAD
CAPSY104130Medicaid
CA0PL104130Medicare ID - Type Unspecified