Provider Demographics
NPI:1215159652
Name:WAGGONER, STEVEN DALE (MA)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:DALE
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WIMER ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520
Mailing Address - Country:US
Mailing Address - Phone:541-778-1336
Mailing Address - Fax:
Practice Address - Street 1:2060 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097
Practice Address - Country:US
Practice Address - Phone:530-841-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT85869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist