MEDICARE: MADISON WADDILL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	121368	TX

General Provider Information

NPI Number	:	1093599441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON WADDILL

Provider Business Mailing Address
First Line	:	55 JALAPENO CT
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6198
Country	:	US
Telephone Number	:	979-248-1999
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 W 11TH ST
Second Line	:
City	:	FREEPORT
State	:	TX
Zip	:	77541-5346
Country	:	US
Telephone Number	:	979-730-7175
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	08/24/2023

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Directions to “ MADISON WADDILL ” Practice Location

Language	Start Address	Practice Location

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