Provider Demographics
NPI:1356058978
Name:WAGGONER, TATE ALLEN (QMHP-C)
Entity type:Individual
Prefix:MR
First Name:TATE
Middle Name:ALLEN
Last Name:WAGGONER
Suffix:
Gender:
Credentials:QMHP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:1631 SW COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6025
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-467-4077
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25-QMHP-C-001612101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500814541Medicaid