Provider Demographics
NPI:1366113797
Name:WADDELL, LEVI JAMES
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:JAMES
Last Name:WADDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 1ST AVE NW APT 407
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-3344
Mailing Address - Country:US
Mailing Address - Phone:605-408-6586
Mailing Address - Fax:
Practice Address - Street 1:400 1ST AVE NW APT 407
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3344
Practice Address - Country:US
Practice Address - Phone:605-408-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician