Provider Demographics
NPI:1518086354
Name:WAGGENER, ELLEN L (PHD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:L
Last Name:WAGGENER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 NORTH RD
Mailing Address - Street 2:ST FRANCIS HOSPITAL MENTAL HEALTH CLINIC
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601
Mailing Address - Country:US
Mailing Address - Phone:845-431-8286
Mailing Address - Fax:845-485-4113
Practice Address - Street 1:241 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1154
Practice Address - Country:US
Practice Address - Phone:845-431-8872
Practice Address - Fax:845-485-4113
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007671-1103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00273845Medicaid
NY00273845Medicaid