Provider Demographics
NPI:1912374786
Name:DANDRIDGE, WAVERLY
Entity Type:Individual
Prefix:
First Name:WAVERLY
Middle Name:
Last Name:DANDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-2015
Mailing Address - Country:US
Mailing Address - Phone:804-240-6252
Mailing Address - Fax:804-562-4411
Practice Address - Street 1:3106 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-2015
Practice Address - Country:US
Practice Address - Phone:804-240-6252
Practice Address - Fax:804-562-4411
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0167851648OtherAPI