Healthcare Provider Details

I. General information

NPI: 1174697338
Provider Name (Legal Business Name): SUSAN LAUDERDALE WALDO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 SW WINDSONG DR
LEES SUMMIT MO
64082-4051
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 660-596-2400
  • Fax:
Mailing address:
  • Phone: 660-826-5960
  • Fax: 660-826-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY01834
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: