Healthcare Provider Details

I. General information

NPI: 1134266083
Provider Name (Legal Business Name): WARDELL INTERESTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 E. 70TH STREET
SHREVEPORT LA
71105
US

IV. Provider business mailing address

2522 E. 70TH STREET
SHREVEPORT LA
71105
US

V. Phone/Fax

Practice location:
  • Phone: 318-795-3388
  • Fax: 318-795-3399
Mailing address:
  • Phone: 318-795-3388
  • Fax: 318-795-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY MACKENZIE WARDELL II
Title or Position: ADMINISTRATOR/SLP
Credential: M.A. CCC-SLP
Phone: 318-795-3388