Provider Demographics
NPI:1801254784
Name:WALDRON, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WALDRON
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 1:3785 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4516
Mailing Address - Country:US
Mailing Address - Phone:231-946-8975
Mailing Address - Fax:231-946-0451
Practice Address - Street 1:3785 VETERANS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4516
Practice Address - Country:US
Practice Address - Phone:231-946-8975
Practice Address - Fax:231-946-0451
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005247101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401005247OtherPROFESSIONAL COUNSELOR LICENSE