Provider Demographics
NPI:1124277223
Name:WALDE, TINA (DNP, PMHNP)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:WALDE
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2439
Mailing Address - Country:US
Mailing Address - Phone:509-834-9213
Mailing Address - Fax:
Practice Address - Street 1:264 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2439
Practice Address - Country:US
Practice Address - Phone:509-834-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10.081826163W00000X
CT12.008564363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification