Provider Demographics
NPI:1952863904
Name:WADDELL, MARK ANTHONY (LPCA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:WADDELL
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28642-2210
Mailing Address - Country:US
Mailing Address - Phone:336-244-6940
Mailing Address - Fax:
Practice Address - Street 1:189 SAMARITANS RIDGE RD STE 104
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2472
Practice Address - Country:US
Practice Address - Phone:336-827-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14667101YP2500X
NCLCAS-24872101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty