Provider Demographics
NPI:1801483102
Name:WADDELL, MASHONDA
Entity type:Individual
Prefix:
First Name:MASHONDA
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:KELLY
Mailing Address - State:NC
Mailing Address - Zip Code:28448-8688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 PHILLIPS DR
Practice Address - Street 2:
Practice Address - City:KELLY
Practice Address - State:NC
Practice Address - Zip Code:28448-8688
Practice Address - Country:US
Practice Address - Phone:910-549-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health