Provider Demographics
NPI:1114954302
Name:WAGGONER, KIMBERLY A (MSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MASSASOIT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2017
Mailing Address - Country:US
Mailing Address - Phone:401-612-7693
Mailing Address - Fax:401-432-1509
Practice Address - Street 1:400 MASSASOIT AVE STE 101
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2017
Practice Address - Country:US
Practice Address - Phone:401-612-7693
Practice Address - Fax:401-432-1500
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW008791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKW10798Medicaid
RI62-23076OtherUNITED BEHAVIORAL HEALTH
RI413014OtherBLUE CHIP
RI31025-9OtherBLUE CROSS