Basic Information
| Provider Information | |||||||||
| NPI: | 1558083204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | LCMHC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8321 NC HIGHWAY 700 | ||||||||
| Address2: | |||||||||
| City: | RUFFIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273269369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363402288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2732 ANN ELIZABETH DR | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272156650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362295905 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2022 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A18071 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.