Provider Demographics
NPI:1346215027
Name:WAGGONER, THOMAS R (LCSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 HOWARD RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15437-1019
Mailing Address - Country:US
Mailing Address - Phone:724-329-5928
Mailing Address - Fax:724-329-5563
Practice Address - Street 1:78 MORGANTOWN ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4239
Practice Address - Country:US
Practice Address - Phone:724-439-4925
Practice Address - Fax:724-439-1218
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0127841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1800448OtherHIGHMARK INC.