Provider Demographics
NPI:1477107126
Name:WAGGONER, CHRISTIAN ONEAL (YPSS CERTIFED)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:ONEAL
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:YPSS CERTIFED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 BROADWAY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:270-442-7121
Mailing Address - Fax:270-443-9692
Practice Address - Street 1:1620 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-2851
Practice Address - Country:US
Practice Address - Phone:270-442-7121
Practice Address - Fax:270-443-9692
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor