Provider Demographics
NPI:1275175374
Name:WADDELL, ELLIS J (RBT)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:J
Last Name:WADDELL
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-1867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2246
Practice Address - Country:US
Practice Address - Phone:706-780-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician