Provider Demographics
NPI:1043244627
Name:WALDO, THOMAS (PHD,HSPP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WALDO
Suffix:
Gender:M
Credentials:PHD,HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 W 10TH ST
Mailing Address - Street 2:C/O RICHARD ROUDEBUSH VA MEDICAL CENTER
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2803
Mailing Address - Country:US
Mailing Address - Phone:317-554-0000
Mailing Address - Fax:317-554-0001
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:C/O RICHARD ROUDEBUSH VA MEDICAL CENTER
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:317-554-0001
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN608960VVMedicare ID - Type Unspecified