Provider Demographics
NPI:1417362088
Name:WADDELL, KRISTIN
Entity Type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 NE BEACON DR
Mailing Address - Street 2:APT 607
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-5781
Mailing Address - Country:US
Mailing Address - Phone:772-486-0461
Mailing Address - Fax:
Practice Address - Street 1:2814 S US HIGHWAY 1
Practice Address - Street 2:SUITE D4
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8120
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health