Provider Demographics
NPI:1417046699
Name:WAGONER, LARRY D (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:WAGONER
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2058 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-5935
Mailing Address - Country:US
Mailing Address - Phone:904-372-7365
Mailing Address - Fax:904-372-7365
Practice Address - Street 1:7545 CENTURION PKWY
Practice Address - Street 2:SUITE # 105
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0579
Practice Address - Country:US
Practice Address - Phone:904-642-2468
Practice Address - Fax:904-642-2469
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1162106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist