Healthcare Provider Details

I. General information

NPI: 1346065265
Provider Name (Legal Business Name): SUZANNE WALDRON MS/CAGS., LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 BOSTON ST APT 5
LYNN MA
01905-1970
US

IV. Provider business mailing address

663 BOSTON ST APT 5
LYNN MA
01905-1970
US

V. Phone/Fax

Practice location:
  • Phone: 978-884-2219
  • Fax:
Mailing address:
  • Phone: 978-884-2219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number330461
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: