Provider Demographics
NPI:1083326110
Name:WAGGONER, ROBIN M (MA, LCDC)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MA, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 COLLEYVILLE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5864
Mailing Address - Country:US
Mailing Address - Phone:817-851-6589
Mailing Address - Fax:
Practice Address - Street 1:5005 COLLEYVILLE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5864
Practice Address - Country:US
Practice Address - Phone:817-851-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12224101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12224OtherCOUNSELING - ADDICTION