Provider Demographics
NPI:1992533087
Name:WADDELL, AVERY ALEXANDRIA
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:ALEXANDRIA
Last Name:WADDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:ALEXANDRIA
Other - Last Name:WADDELL-HOWARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3903 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1426
Mailing Address - Country:US
Mailing Address - Phone:405-585-2971
Mailing Address - Fax:405-585-2983
Practice Address - Street 1:1960 HARPER ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8095
Practice Address - Country:US
Practice Address - Phone:405-281-1040
Practice Address - Fax:405-585-2983
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-24-372796106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician