Healthcare Provider Details

I. General information

NPI: 1407513393
Provider Name (Legal Business Name): WAGGONER BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 TANGLEWOOD DR
GURNEE IL
60031-3431
US

IV. Provider business mailing address

489 TANGLEWOOD DR
GURNEE IL
60031-3431
US

V. Phone/Fax

Practice location:
  • Phone: 224-410-1239
  • Fax:
Mailing address:
  • Phone: 224-410-1239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: ROCKELLE WAGGONER
Title or Position: OWNER
Credential: BCBA
Phone: 224-410-1239