Provider Demographics
NPI:1518038041
Name:WAGGONER, KENNETH RAY (LPC, LADC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 NW 55TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3117
Mailing Address - Country:US
Mailing Address - Phone:580-248-5425
Mailing Address - Fax:
Practice Address - Street 1:4301 MOW-WAY ROAD
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-458-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)