Provider Demographics
NPI:1609971886
Name:WAGGONER, KATHLEEN A (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 2335
Mailing Address - Street 2:
Mailing Address - City:SEDGEWICKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63781-9706
Mailing Address - Country:US
Mailing Address - Phone:573-576-1936
Mailing Address - Fax:573-664-1117
Practice Address - Street 1:400 N WASHINGTON ST STE 111
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1731
Practice Address - Country:US
Practice Address - Phone:573-664-1117
Practice Address - Fax:573-664-1117
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014231101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202194OtherBLUE CROSS BLUE SHIELD
MO738553OtherHEALTHLINK
MO499297703Medicaid
MO431344414WAGOtherUNITY MANAGED MENTAL HEAL