Provider Demographics
NPI:1083764039
Name:WADELTON, BAMBI LYNN (PLHD)
Entity Type:Individual
Prefix:
First Name:BAMBI
Middle Name:LYNN
Last Name:WADELTON
Suffix:
Gender:F
Credentials:PLHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 SAWGRASS VILLAGE CIR
Mailing Address - Street 2:SUITE 46
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5016
Mailing Address - Country:US
Mailing Address - Phone:904-280-8555
Mailing Address - Fax:904-280-8562
Practice Address - Street 1:13000 SAWGRASS VILLAGE CIR
Practice Address - Street 2:SUITE 46
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5016
Practice Address - Country:US
Practice Address - Phone:904-280-8555
Practice Address - Fax:904-280-8562
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical