Provider Demographics
NPI:1821140898
Name:YANCEY WAGGAMAN, REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:YANCEY WAGGAMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:YANCEY WAGGAMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1603
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-1603
Mailing Address - Country:US
Mailing Address - Phone:208-807-2877
Mailing Address - Fax:208-807-2888
Practice Address - Street 1:3071 E FRANKLIN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2376
Practice Address - Country:US
Practice Address - Phone:208-807-2877
Practice Address - Fax:208-807-2888
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW11691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010135718OtherREGENCE BLUE SHIELD
IDL1831OtherBLUE CROSS OF ID
ID000010135718OtherREGENCE BLUE SHIELD