MEDICARE: DR. KATHLEEN J WADDELL PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY5636	CA

General Provider Information

NPI Number	:	1285629329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN J WADDELL PHD

Provider Business Mailing Address
First Line	:	815 SKYLINE DR
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-1053
Country	:	US
Telephone Number	:	805-541-8116
Fax Number	:	805-542-0302

Provider Business Practice Location Address
First Line	:	1521 HIGUERA ST
Second Line	:	STE E
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-2958
Country	:	US
Telephone Number	:	805-541-8116
Fax Number	:	805-542-0302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/08/2007

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