MEDICARE: SUSAN WALD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	MT1647

General Provider Information

NPI Number	:	1396335717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN WALD

Provider Business Mailing Address
First Line	:	1000 JEFFERSON ST STE 2C
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24504-1724
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 METROWEST BLVD STE 305
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32835-3291
Country	:	US
Telephone Number	:	754-400-5514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2021
Last Update Date	:	01/20/2021

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Directions to “ SUSAN WALD ” Practice Location

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