Provider Demographics
NPI:1629596671
Name:WAGGONER, LORI REEDS (MS CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:REEDS
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1370
Mailing Address - Country:US
Mailing Address - Phone:618-357-5161
Mailing Address - Fax:618-357-9431
Practice Address - Street 1:301 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1370
Practice Address - Country:US
Practice Address - Phone:618-357-5161
Practice Address - Fax:618-357-9431
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty