Healthcare Provider Details

I. General information

NPI: 1407572340
Provider Name (Legal Business Name): VALERIE WADDLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S MAIN ST STE C
CARLSBAD NM
88220-6207
US

IV. Provider business mailing address

36 E TWOHIG AVE STE 600
SAN ANGELO TX
76903-6486
US

V. Phone/Fax

Practice location:
  • Phone: 575-249-2561
  • Fax: 575-541-3645
Mailing address:
  • Phone: 325-944-2561
  • Fax: 325-939-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2024-0504
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: