Basic Information
| Provider Information | |||||||||
| NPI: | 1013139203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALDO PSYCHOLOGICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3904 SW WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640824051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605962400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | WALDO | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6605962400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 26423017 | 01 | MO | BCBS | OTHER |