Provider Demographics
NPI:1518246859
Name:WAGGONER, BRITTTANY (MA)
Entity Type:Individual
Prefix:
First Name:BRITTTANY
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 N TAPADERO DR APT C
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-5823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1288 N TAPADERO DR APT C
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-5823
Practice Address - Country:US
Practice Address - Phone:928-499-8069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4116576103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool