Provider Demographics
NPI:1710219530
Name:WADDELL, TAMI RENNELS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAMI
Middle Name:RENNELS
Last Name:WADDELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:R
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:906 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3816
Mailing Address - Country:US
Mailing Address - Phone:503-842-8201
Mailing Address - Fax:503-815-1870
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX325601041C0700X
1041C0700X
ORL65681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500690672Medicaid