Provider Demographics
NPI:1841748795
Name:WADDELL, PAMELA L (LPCC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:WADDELL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11369 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:44452-9782
Mailing Address - Country:US
Mailing Address - Phone:330-965-9999
Mailing Address - Fax:330-757-0000
Practice Address - Street 1:1947 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6644
Practice Address - Country:US
Practice Address - Phone:330-965-9999
Practice Address - Fax:330-757-0000
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700822101YM0800X
OHR2001929101YM0800X
OHE.2001929101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337839Medicaid