Provider Demographics
NPI:1518625763
Name:WAGGONER, CYNTHIA (PSYD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11167
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46856-1167
Mailing Address - Country:US
Mailing Address - Phone:574-546-1900
Mailing Address - Fax:
Practice Address - Street 1:4400 EAST COMMONS WAY
Practice Address - Street 2:SUITE 125
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4637103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical