Healthcare Provider Details

I. General information

NPI: 1720119340
Provider Name (Legal Business Name): CRAIG MILYN WADDELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 AGUAJITO RD SUITE 103
MONTEREY CA
93940-4887
US

IV. Provider business mailing address

1200 AGUAJITO RD SUITE 103
MONTEREY CA
93940-4887
US

V. Phone/Fax

Practice location:
  • Phone: 831-647-7652
  • Fax: 831-647-7040
Mailing address:
  • Phone: 831-647-7652
  • Fax: 831-647-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS12529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: