Healthcare Provider Details

I. General information

NPI: 1558587543
Provider Name (Legal Business Name): KATHLEEN GRADY WALDRON PH.D APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 - 119 ROOSEVELT AVE. UCPC BEHAVIORAL HEALTHCARE
PLAINFIELD NJ
07060
US

IV. Provider business mailing address

117 - 119 ROOSEVELT AVE. UCPC BEHAVIORAL HEALTHCARE
PLAINFIELD NJ
07060
US

V. Phone/Fax

Practice location:
  • Phone: 908-756-6870
  • Fax: 908-756-5566
Mailing address:
  • Phone: 908-756-6870
  • Fax: 908-756-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number355100358000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number26NR05725200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number26NC05725200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: