Healthcare Provider Details

I. General information

NPI: 1164233003
Provider Name (Legal Business Name): LUCILLE WAAGEN PH.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WAYLAND AVE
PROVIDENCE RI
02906-4371
US

IV. Provider business mailing address

630 SMITHFIELD RD APT 708
NORTH PROVIDENCE RI
02904-2930
US

V. Phone/Fax

Practice location:
  • Phone: 401-330-5882
  • Fax:
Mailing address:
  • Phone: 406-478-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number655
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: