Provider Demographics
NPI:1275639858
Name:WAGGENER, ROBERT F (MDIV, LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:F
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:MDIV, LCSW
Other - Prefix:MR
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:WAGGENER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDIV, LCSW
Mailing Address - Street 1:11914 JUSTICE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2372
Mailing Address - Country:US
Mailing Address - Phone:225-291-4282
Mailing Address - Fax:225-291-7133
Practice Address - Street 1:11914 JUSTICE AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2372
Practice Address - Country:US
Practice Address - Phone:225-291-4282
Practice Address - Fax:225-291-7133
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4069OtherLIC CLINICAL SW
LA6241OtherAMER ASS PASTORAL COUNSE