Provider Demographics
NPI:1346911450
Name:WAGGONER, GRANT JORDAN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:JORDAN
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25412 COACH SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5861
Mailing Address - Country:US
Mailing Address - Phone:702-533-8324
Mailing Address - Fax:
Practice Address - Street 1:24632 SAN JUAN AVE STE 110
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3830
Practice Address - Country:US
Practice Address - Phone:702-533-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health