Basic Information
Provider Information | |||||||||
NPI: | 1720154453 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDEN | ||||||||
FirstName: | BOBBY | ||||||||
MiddleName: | DEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ASW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PMB 182 | ||||||||
Address2: | 975 EAST AVE | ||||||||
City: | CHICO | ||||||||
State: | CA | ||||||||
PostalCode: | 95926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5305664181 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 107 PARMAC ROAD | ||||||||
Address2: | SUITE 2 | ||||||||
City: | CHICO | ||||||||
State: | CA | ||||||||
PostalCode: | 95926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308912784 | ||||||||
FaxNumber: | 5308912809 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 17044 | CA | X |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 17044 | CA | X |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 17044 | 01 | CA | ASW | OTHER |