Provider Demographics
NPI:1558083204
Name:WADDELL, BRADLEY MICHAEL (LCMHC-A)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MICHAEL
Last Name:WADDELL
Suffix:
Gender:M
Credentials:LCMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 NC HIGHWAY 700
Mailing Address - Street 2:
Mailing Address - City:RUFFIN
Mailing Address - State:NC
Mailing Address - Zip Code:27326-9369
Mailing Address - Country:US
Mailing Address - Phone:336-340-2288
Mailing Address - Fax:
Practice Address - Street 1:2732 ANN ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6650
Practice Address - Country:US
Practice Address - Phone:336-229-5905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health