Healthcare Provider Details

I. General information

NPI: 1639161060
Provider Name (Legal Business Name): WALDA C CHESNUT LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 09/08/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 NOTT STREET EAST SUITE 3
NISKAYUNA NY
12309
US

IV. Provider business mailing address

5 HEMPHILL PLACE SUITE 121
MALTA NY
12020-4423
US

V. Phone/Fax

Practice location:
  • Phone: 518-374-6263
  • Fax: 518-289-5225
Mailing address:
  • Phone: 518-289-5072
  • Fax: 518-289-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number069258-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: