Provider Demographics
NPI:1275867418
Name:WAGGONER, KELLY CONDON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CONDON
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CHRISTINE
Other - Last Name:CONDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 PACIFIC COAST HWY STE 215
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2701
Mailing Address - Country:US
Mailing Address - Phone:310-567-0456
Mailing Address - Fax:
Practice Address - Street 1:2200 PACIFIC COAST HWY STE 215
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2701
Practice Address - Country:US
Practice Address - Phone:310-567-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24570103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical