Provider Demographics
NPI:1386036382
Name:WAGGONER, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4576
Mailing Address - Country:US
Mailing Address - Phone:479-464-1060
Mailing Address - Fax:479-271-6307
Practice Address - Street 1:750 MATHIAS DR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0741
Practice Address - Country:US
Practice Address - Phone:479-750-1272
Practice Address - Fax:479-750-1261
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor