Provider Demographics
NPI:1578230108
Name:WAGONER, MEGHAN ROSE
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ROSE
Last Name:WAGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSY
Other - Middle Name:ROSE
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7020
Mailing Address - Country:US
Mailing Address - Phone:804-644-9590
Mailing Address - Fax:
Practice Address - Street 1:200 N 22ND ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7020
Practice Address - Country:US
Practice Address - Phone:804-644-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional