Provider Demographics
NPI:1578517439
Name:WAGGONER, CRAIG D (PHD, MPAP)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:D
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:PHD, MPAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4603
Mailing Address - Country:US
Mailing Address - Phone:337-475-8022
Mailing Address - Fax:337-475-8054
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-8022
Practice Address - Fax:337-475-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMPAP.000029103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANPP000Medicare UPIN