Provider Demographics
NPI:1982374583
Name:WAGONER, TONYA LAVON (LGPC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LAVON
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 W BRADDOCK RD APT 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-4733
Mailing Address - Country:US
Mailing Address - Phone:202-819-3316
Mailing Address - Fax:
Practice Address - Street 1:6512 RONALD RD APT T1
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4481
Practice Address - Country:US
Practice Address - Phone:202-819-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12354101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health