Provider Demographics
NPI:1366624298
Name:WAGONER, EDDIE L (LPC, LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:L
Last Name:WAGONER
Suffix:
Gender:M
Credentials:LPC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 PECAN GROVE RD E
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-1767
Mailing Address - Country:US
Mailing Address - Phone:903-893-7768
Mailing Address - Fax:903-893-4979
Practice Address - Street 1:804 PECAN GROVE RD E
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-1767
Practice Address - Country:US
Practice Address - Phone:903-893-7768
Practice Address - Fax:903-893-4979
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01315101YP2500X
TX104731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional