Basic Information
Provider Information
NPI: 1003001744
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALDEN
FirstName: RON
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 314 HILLCREST DR APT B
Address2:  
City: DURANGO
State: CO
PostalCode: 813016582
CountryCode: US
TelephoneNumber: 9079030580
FaxNumber:  
Practice Location
Address1: 2700 FARMINGTON AVE
Address2:  
City: FARMINGTON
State: NM
PostalCode: 874014559
CountryCode: US
TelephoneNumber: 5053267878
FaxNumber: 5053267879
Other Information
ProviderEnumerationDate: 09/06/2007
LastUpdateDate: 09/21/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X  Y Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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