Provider Demographics
NPI:1104791664
Name:WADDILL, ASHTEN (LMSW)
Entity type:Individual
Prefix:
First Name:ASHTEN
Middle Name:
Last Name:WADDILL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2536
Mailing Address - Country:US
Mailing Address - Phone:870-776-4655
Mailing Address - Fax:870-925-1572
Practice Address - Street 1:2904 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2536
Practice Address - Country:US
Practice Address - Phone:870-776-4655
Practice Address - Fax:870-925-1572
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR28034-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker