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General NPI Number Information
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NPI Number | 1609140722
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Entity Type | Individual
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Provider Name | SEAN PAUL WALDRON MSW
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Gender | Male
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Dates
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Enumeration Date | 03/07/2012
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Last Update Date | 03/07/2012
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Provider Practice Location Address
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Address Line | 1070 HILINE RD STE 210
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City | POCATELLO
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State | ID
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Zip | 83201-2947
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Country | US
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Telephone | 208-478-9081
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Fax | 208-478-4999
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Provider Business Mailing Address
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Address Line | 1597 SUMMER WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8258
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Country | US
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Telephone | 208-522-0175
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 31792
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License Number State | ID
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