Provider Demographics
NPI:1871728048
Name:WADDELL, JOHN ROY (LPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROY
Last Name:WADDELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-3558
Mailing Address - Country:US
Mailing Address - Phone:865-774-4432
Mailing Address - Fax:865-453-4311
Practice Address - Street 1:114 BRUCE ST
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3558
Practice Address - Country:US
Practice Address - Phone:865-774-4432
Practice Address - Fax:865-453-4311
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000001715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLPC0000001715OtherLICENSED PROFESSIONAL COUNSELOR