Provider Demographics
NPI:1811324502
Name:WALD, TRINA LANE
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:LANE
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 1:106 S HOLMEN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9467
Mailing Address - Country:US
Mailing Address - Phone:608-526-9965
Mailing Address - Fax:
Practice Address - Street 1:198 COUNTY ROAD DF
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-9512
Practice Address - Country:US
Practice Address - Phone:920-386-3400
Practice Address - Fax:920-386-4186
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3878-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist