Provider Demographics
NPI:1285629329
Name:WADDELL, KATHLEEN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:J
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1053
Mailing Address - Country:US
Mailing Address - Phone:805-541-8116
Mailing Address - Fax:805-542-0302
Practice Address - Street 1:1521 HIGUERA ST
Practice Address - Street 2:STE E
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2958
Practice Address - Country:US
Practice Address - Phone:805-541-8116
Practice Address - Fax:805-542-0302
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5636Medicare ID - Type Unspecified