Provider Demographics
NPI:1043569122
Name:WADDELL, DOROTHY RENEE (PTA)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:RENEE
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3852 PINTAIL DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-3418
Mailing Address - Country:US
Mailing Address - Phone:262-949-9422
Mailing Address - Fax:
Practice Address - Street 1:3852 PINTAIL DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3418
Practice Address - Country:US
Practice Address - Phone:262-949-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1904-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant