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General NPI Number Information
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NPI Number | 1811206204
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Entity Type | Individual
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Provider Name | KATHLEEN WAGGONER PETTY LCSW, CSAC
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Gender | Female
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Dates
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Enumeration Date | 10/01/2010
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Last Update Date | 10/01/2010
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Provider Practice Location Address
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Address Line | 19441 GOLF VISTA PLZ SUITE 110
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City | LANSDOWNE
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State | VA
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Zip | 20176-8269
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Country | US
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Telephone | 703-402-3080
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Fax |
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Provider Business Mailing Address
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Address Line | 2607 DEERDELL LN
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City | RESTON
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State | VA
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Zip | 20191-2114
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Country | US
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Telephone | 703-476-5822
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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