1609971886 NPI number — MRS. KATHLEEN A WAGGONER LPC

Table of content: MRS. KATHLEEN A WAGGONER LPC (NPI 1609971886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609971886 NPI number — MRS. KATHLEEN A WAGGONER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGGONER
Provider First Name:
KATHLEEN
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609971886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 2 BOX 2335
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEDGEWICKVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63781-9706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-576-1936
Provider Business Mailing Address Fax Number:
573-664-1117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N WASHINGTON ST STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63640-1731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-664-1117
Provider Business Practice Location Address Fax Number:
573-664-1117
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2004014231 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202194 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 738553 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 499297703 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431344414WAG . This is a "UNITY MANAGED MENTAL HEAL" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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