Provider Demographics
NPI:1801087911
Name:WAGHORN, KRISTEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WAGHORN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6246
Mailing Address - Country:US
Mailing Address - Phone:706-364-6712
Mailing Address - Fax:706-364-6172
Practice Address - Street 1:2315 CENTRAL AVE STE C
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6246
Practice Address - Country:US
Practice Address - Phone:706-364-6712
Practice Address - Fax:706-364-6172
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA673942428CMedicaid