Basic Information
| Provider Information | |||||||||
| NPI: | 1649309154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDEN | ||||||||
| FirstName: | CHERYL | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E MAIN ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975016041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895526 | ||||||||
| FaxNumber: | 5417895203 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 S RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975017841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 00289702 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 009493 | 05 | OR | MEDICAID |