Provider Demographics
NPI:1871937383
Name:WALD, DAVID EDWARD (LMP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:WALD
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101EAST MAIN STREET SUITE 201
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:98272
Mailing Address - Country:US
Mailing Address - Phone:360-421-8100
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-421-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60263726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist