Provider Demographics
NPI:1316188121
Name:WAGGONER, KATHRYN KIM (PSYD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:KIM
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:KIM
Other - Last Name:MULLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2112 BIENVILLE BLVD STE K
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3067
Mailing Address - Country:US
Mailing Address - Phone:228-819-2171
Mailing Address - Fax:833-779-1879
Practice Address - Street 1:2112 BIENVILLE BLVD STE K
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3067
Practice Address - Country:US
Practice Address - Phone:228-819-2171
Practice Address - Fax:228-205-4986
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1577103TH0004X
DC7393103TH0004X
MS591032103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06585020Medicaid