Basic Information
| Provider Information | |||||||||
| NPI: | 1780917427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WADDELL | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | JANE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2161 NW MILITARY HWY | ||||||||
| Address2: | STE 308 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103413336 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 MDG | ||||||||
| Address2: | 7319 BALMER ST. BLDG 546 | ||||||||
| City: | HILL AFB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017773497 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7754639-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 260022408 | 01 | UT | RAILROAD MEDICARE | OTHER | 876000308007 | 05 | UT | MEDICAID |