Provider Demographics
NPI:1225189764
Name:WADDELL, TARSYIA MELISSA (LPCLCDCCEAPSAP)
Entity Type:Individual
Prefix:MS
First Name:TARSYIA
Middle Name:MELISSA
Last Name:WADDELL
Suffix:
Gender:F
Credentials:LPCLCDCCEAPSAP
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 411
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-0008
Mailing Address - Country:US
Mailing Address - Phone:214-738-6869
Mailing Address - Fax:402-233-3466
Practice Address - Street 1:900 E PARK BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5465
Practice Address - Country:US
Practice Address - Phone:214-738-6869
Practice Address - Fax:402-233-3466
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7317101YA0400X
TX16012101YP2500X
IL180002879101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156099701Medicaid