MEDICARE: KRYSTAL WALDO PHD

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	103T00000X	Psychologist	6301016911	MI

General Provider Information

NPI Number	:	1629594627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL WALDO PHD

Provider Business Mailing Address
First Line	:	501 BELLE HALL PKWY UNIT 202
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-8322
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 BELLE HALL PKWY UNIT 202
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-8322
Country	:	US
Telephone Number	:	843-620-7748
Fax Number	:

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

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	07/12/2022

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