Healthcare Provider Details

I. General information

NPI: 1790940286
Provider Name (Legal Business Name): LINDSEY WAGGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 HARBER ROAD
GROVE OK
74344
US

IV. Provider business mailing address

56625 E 130 ROAD
MIAMI OK
74354
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-4434
  • Fax: 918-786-4435
Mailing address:
  • Phone: 918-919-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: