Provider Demographics
NPI:1194590786
Name:WADDELL, KIMBERLY KAYE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAYE
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:903-445-8303
Mailing Address - Fax:
Practice Address - Street 1:129 E BRANCH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-3203
Practice Address - Country:US
Practice Address - Phone:903-445-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst