Provider Demographics
NPI:1295391779
Name:WADSWORTH, MADELINE DAWN (LAC)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:DAWN
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 LUNSFORD RD APT 3240
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17503 LA CANTERA PKWY STE 123
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-8208
Practice Address - Country:US
Practice Address - Phone:512-202-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
TX1974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist