Provider Demographics
NPI:1376305409
Name:WAGGONER, BRIAN (LAC, NCC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19369 NEILLS BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-8503
Mailing Address - Country:US
Mailing Address - Phone:630-740-7705
Mailing Address - Fax:
Practice Address - Street 1:5310 W VILLAGE PKWY STE 4
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8201
Practice Address - Country:US
Practice Address - Phone:479-435-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2401024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health