Healthcare Provider Details

I. General information

NPI: 1609140722
Provider Name (Legal Business Name): SEAN PAUL WALDRON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 HILINE RD STE 210
POCATELLO ID
83201-2947
US

IV. Provider business mailing address

1597 SUMMER WAY
IDAHO FALLS ID
83404-8258
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax: 208-478-4999
Mailing address:
  • Phone: 208-522-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number31792
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: