Healthcare Provider Details

I. General information

NPI: 1376603092
Provider Name (Legal Business Name): TIM WALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 KANSAS CITY ST
RAPID CITY SD
57701-5036
US

IV. Provider business mailing address

PO BOX 1007
RAPID CITY SD
57709-1007
US

V. Phone/Fax

Practice location:
  • Phone: 605-222-7336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1343
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1137
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1351
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: