Provider Demographics
NPI:1770505851
Name:WARDELL, WILLIAM WALLACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALLACE
Last Name:WARDELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 YOAKUM BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-5818
Mailing Address - Country:US
Mailing Address - Phone:713-850-0049
Mailing Address - Fax:
Practice Address - Street 1:4314 YOAKUM BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-5818
Practice Address - Country:US
Practice Address - Phone:713-850-0049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23489103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034153901Medicaid
TX034153902Medicaid
TXP00930109OtherRR MCR
TXP00930109OtherRR MCR
TX00JD09Medicare ID - Type Unspecified