Provider Demographics
NPI:1609172873
Name:WADSWORTH, KENDALL K (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:K
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11569 NORTHCROSS LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-3617
Mailing Address - Country:US
Mailing Address - Phone:325-650-2102
Mailing Address - Fax:
Practice Address - Street 1:11569 NORTHCROSS LN
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-3617
Practice Address - Country:US
Practice Address - Phone:325-650-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1396867966Medicaid