Provider Demographics
NPI:1285118117
Name:WALD, ROBERT J (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WALD
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 CARDIGAN RD
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1206
Mailing Address - Country:US
Mailing Address - Phone:978-590-8172
Mailing Address - Fax:
Practice Address - Street 1:97 CARDIGAN RD
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1206
Practice Address - Country:US
Practice Address - Phone:978-590-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106228104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA106228OtherLICENSED INDEPENDENT CLINICAL SOCIAL WORKER