MEDICARE: NANNA SOPHIE LUISA WALDROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1588437024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANNA SOPHIE LUISA WALDROUP

Provider Business Mailing Address
First Line	:	6 NORTON ST APT 3
Second Line	:
City	:	DORCHESTER
State	:	MA
Zip	:	02125-2994
Country	:	US
Telephone Number	:	857-540-2530
Fax Number	:

Provider Business Practice Location Address
First Line	:	7219 19TH AVE STE 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-5739
Country	:	US
Telephone Number	:	857-271-1973
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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