Provider Demographics
NPI:1699982371
Name:WOLDT, BRADLEY D (PHD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:WOLDT
Suffix:
Gender:M
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:PO BOX 8563
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-8563
Mailing Address - Country:US
Mailing Address - Phone:605-692-6011
Mailing Address - Fax:605-692-6011
Practice Address - Street 1:928 4TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2171
Practice Address - Country:US
Practice Address - Phone:605-692-6011
Practice Address - Fax:605-692-6011
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical