Provider Demographics
NPI:1487261350
Name:WARDELL, MIA K D
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:K D
Last Name:WARDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 CALBORO DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-2916
Mailing Address - Country:US
Mailing Address - Phone:408-891-2660
Mailing Address - Fax:
Practice Address - Street 1:4400 KELLER AVE STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4229
Practice Address - Country:US
Practice Address - Phone:510-639-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14935235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist