Healthcare Provider Details

I. General information

NPI: 1093252751
Provider Name (Legal Business Name): BL WADSWORTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 ALABAMA AVE
JASPER AL
35501-4717
US

IV. Provider business mailing address

1511 ALABAMA AVE
JASPER AL
35501-4717
US

V. Phone/Fax

Practice location:
  • Phone: 205-295-1001
  • Fax: 205-295-1005
Mailing address:
  • Phone: 205-295-1001
  • Fax: 205-295-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0992842-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60720812
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP9706
License Number StateAZ

VIII. Authorized Official

Name: BRETT LEE WADSWORTH
Title or Position: OWNER
Credential: CRNP
Phone: 205-295-1001