Provider Demographics
NPI:1669843710
Name:WADDELL, THERESA (CADC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NEW GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8373
Mailing Address - Country:US
Mailing Address - Phone:270-839-6743
Mailing Address - Fax:
Practice Address - Street 1:725 NEW GLENDALE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8373
Practice Address - Country:US
Practice Address - Phone:270-839-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)