Healthcare Provider Details

I. General information

NPI: 1316188121
Provider Name (Legal Business Name): KATHRYN KIM WAGGONER PSY.D., ABPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN KIM MULLIN

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 06/10/2024
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 BIENVILLE BLVD STE K
OCEAN SPRINGS MS
39564-3067
US

IV. Provider business mailing address

2112 BIENVILLE BLVD STE K
OCEAN SPRINGS MS
39564-3067
US

V. Phone/Fax

Practice location:
  • Phone: 228-819-2171
  • Fax: 228-205-4986
Mailing address:
  • Phone: 228-819-2171
  • Fax: 833-779-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1577
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number591032
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: