Provider Demographics
NPI:1023258704
Name:WAGGONER, LINDA K (LPC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:K
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4265 NORTH 1400 EAST
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316
Mailing Address - Country:US
Mailing Address - Phone:208-490-0800
Mailing Address - Fax:
Practice Address - Street 1:493 EASTLAND
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83303-0047
Practice Address - Country:US
Practice Address - Phone:208-732-0995
Practice Address - Fax:208-732-0993
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805997100Medicaid