Provider Demographics
NPI:1811206204
Name:PETTY, KATHLEEN WAGGONER (LCSW, CSAC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:WAGGONER
Last Name:PETTY
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 DEERDELL LN
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2114
Mailing Address - Country:US
Mailing Address - Phone:703-476-5822
Mailing Address - Fax:
Practice Address - Street 1:19441 GOLF VISTA PLZ
Practice Address - Street 2:SUITE 110
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8269
Practice Address - Country:US
Practice Address - Phone:703-402-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)