Healthcare Provider Details

I. General information

NPI: 1336861830
Provider Name (Legal Business Name): REBECCA WAGGONER LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 BIGGY ST
LOS ANGELES CA
90033-1006
US

IV. Provider business mailing address

700 WESTMOUNT DR APT 302
WEST HOLLYWOOD CA
90069-5142
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-0911
  • Fax:
Mailing address:
  • Phone: 714-913-3701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC001639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: