Provider Demographics
NPI:1588437024
Name:WALDROUP, NANNA SOPHIE LUISA
Entity type:Individual
Prefix:
First Name:NANNA
Middle Name:SOPHIE LUISA
Last Name:WALDROUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NORTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2994
Mailing Address - Country:US
Mailing Address - Phone:857-540-2530
Mailing Address - Fax:
Practice Address - Street 1:7219 19TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5739
Practice Address - Country:US
Practice Address - Phone:857-271-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health