Provider Demographics
NPI:1124246145
Name:LAUDERDALE, RONALD WAYNE (MSSW)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:WAYNE
Last Name:LAUDERDALE
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 WEST ADAIR DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1527
Mailing Address - Country:US
Mailing Address - Phone:865-688-3326
Mailing Address - Fax:
Practice Address - Street 1:5117 SCHUBERT RD STE #A
Practice Address - Street 2:CHRISTIAN COUNSELING CENTER
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912-3871
Practice Address - Country:US
Practice Address - Phone:865-689-3326
Practice Address - Fax:865-689-3326
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN138577OtherVALUE OPTIMA
TN5694663OtherAETNA
TN737240000OtherMAGELLAN
TN197473293284Medicaid
TN3101178OtherBC BST