Provider Demographics
NPI:1700665254
Name:WADHAM, CONNIE LOUISE (LMT, LMSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LOUISE
Last Name:WADHAM
Suffix:
Gender:F
Credentials:LMT, LMSW
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:LOUISE
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3613 WILLIAMS DR STE 304
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1369
Mailing Address - Country:US
Mailing Address - Phone:512-400-4247
Mailing Address - Fax:
Practice Address - Street 1:3613 WILLIAMS DR STE 304
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1369
Practice Address - Country:US
Practice Address - Phone:512-400-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT025785225700000X
TX68854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist