Provider Demographics
NPI:1215140074
Name:WALDER, DEBORAH J (PHD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:WALDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PIERREPONT ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2452
Mailing Address - Country:US
Mailing Address - Phone:718-404-2118
Mailing Address - Fax:
Practice Address - Street 1:62 PIERREPONT ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-2452
Practice Address - Country:US
Practice Address - Phone:718-404-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016073103G00000X, 103TC0700X
MA8252103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical