Healthcare Provider Details

I. General information

NPI: 1558047779
Provider Name (Legal Business Name): MARY WADDELL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3198 US ROUTE 60 STE A
ONA WV
25545-9507
US

IV. Provider business mailing address

119 THOROUGHBRED WAY
MILTON WV
25541-9568
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-9430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: