=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871904128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL WAGGONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2014
-----------------------------------------------------
Last Update Date | 12/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14900 DETROIT AVE STE 206
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-543-5232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14900 DETROIT AVE STE 206
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-543-5232
-----------------------------------------------------
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 | E.1700304
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------