Healthcare Provider Details

I. General information

NPI: 1801022181
Provider Name (Legal Business Name): WADONNA WELLS LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 2ND AVE NW
ARDMORE OK
73401-6202
US

IV. Provider business mailing address

2530 S COMMERCE ST
ARDMORE OK
73401-5519
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-3252
  • Fax: 580-226-3849
Mailing address:
  • Phone: 580-490-6342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number596
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: