Provider Demographics
NPI:1396454864
Name:WADDELL, LEESA MARIE (PRS)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:MARIE
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-2912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:258 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-2912
Practice Address - Country:US
Practice Address - Phone:740-972-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No251B00000XAgenciesCase Management