Provider Demographics
NPI:1851488803
Name:WADDELL, MARILYN PATRICIA (MED, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:PATRICIA
Last Name:WADDELL
Suffix:
Gender:F
Credentials:MED, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 TODD DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-3240
Mailing Address - Country:US
Mailing Address - Phone:919-920-4759
Mailing Address - Fax:
Practice Address - Street 1:405 TODD DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-3240
Practice Address - Country:US
Practice Address - Phone:919-920-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1068235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411008Medicaid