Healthcare Provider Details

I. General information

NPI: 1033529813
Provider Name (Legal Business Name): DERRICK WAGONER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

IV. Provider business mailing address

104 REYNOLDS RD
GLASGOW KY
42141-1177
US

V. Phone/Fax

Practice location:
  • Phone: 270-678-4801
  • Fax: 270-678-3866
Mailing address:
  • Phone: 270-678-4801
  • Fax: 270-678-3866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1839
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number172294
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: