Provider Demographics
NPI:1689123085
Name:WADDELL, HOLLY (MED, LPC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79412-2619
Mailing Address - Country:US
Mailing Address - Phone:806-412-4720
Mailing Address - Fax:
Practice Address - Street 1:2126 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-2619
Practice Address - Country:US
Practice Address - Phone:806-412-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73074101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional