=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376305409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN WAGGONER LAC, NCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2024
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5310 W VILLAGE PKWY STE 4
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-435-8388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19369 NEILLS BLUFF RD
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-8503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-740-7705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A2401024
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------