Provider Demographics
NPI:1578709838
Name:WAGGONER, ELIZABETH ADRIENNE (MS, MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ADRIENNE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MS, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 E SUNSET RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3218
Mailing Address - Country:US
Mailing Address - Phone:702-629-7024
Mailing Address - Fax:702-794-4501
Practice Address - Street 1:3663 E SUNSET RD
Practice Address - Street 2:SUITE 104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3218
Practice Address - Country:US
Practice Address - Phone:702-629-7024
Practice Address - Fax:702-794-4501
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVR07035106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist