Provider Demographics
NPI:1386815207
Name:WAGGONER, HEATHER LYNNE (LISWS)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LYNNE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LISWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WAYNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410
Mailing Address - Country:US
Mailing Address - Phone:937-496-2000
Mailing Address - Fax:937-463-2901
Practice Address - Street 1:600 WAYNE AVENUE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410
Practice Address - Country:US
Practice Address - Phone:937-496-2000
Practice Address - Fax:937-463-2901
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0007672S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000003211683OtherANTHEM BCBS
OHWASW27451Medicare PIN