Provider Demographics
NPI:1629505573
Name:WIGGINS, VERNON ARCHIE III (BCBA)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:ARCHIE
Last Name:WIGGINS
Suffix:III
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 S LHS DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-8603
Mailing Address - Country:US
Mailing Address - Phone:210-323-3153
Mailing Address - Fax:
Practice Address - Street 1:242 S LHS DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-8603
Practice Address - Country:US
Practice Address - Phone:210-323-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79828101YP2500X
TX1479103K00000X
TXMT034888225700000X
CO1-14-17593103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist