Healthcare Provider Details

I. General information

NPI: 1336037456
Provider Name (Legal Business Name): LYNDSI WALDECK LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 N 75TH AVE
PHOENIX AZ
85035-1216
US

IV. Provider business mailing address

1375 N SCOTTSDALE RD STE 200
SCOTTSDALE AZ
85257-3429
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 480-877-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-22677
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: