Provider Demographics
NPI:1912012204
Name:WAGNON, DARRIN (LPC)
Entity Type:Individual
Prefix:
First Name:DARRIN
Middle Name:
Last Name:WAGNON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 HORSESHOE FARM RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:VA
Mailing Address - Zip Code:24136-3471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:363 HORSESHOE FARM RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:VA
Practice Address - Zip Code:24136-3471
Practice Address - Country:US
Practice Address - Phone:540-626-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003867101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010281547Medicaid