MEDICARE: MR. ROBERT F WAGGENER M.DIV, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	4069	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4069	OTHER	LA	LIC CLINICAL SW
2	6241	OTHER	LA	AMER ASS PASTORAL COUNSE

General Provider Information

NPI Number	:	1275639858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT F WAGGENER M.DIV, LCSW

Provider Business Mailing Address
First Line	:	11914 JUSTICE AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2372
Country	:	US
Telephone Number	:	225-291-4282
Fax Number	:	225-291-7133

Provider Business Practice Location Address
First Line	:	11914 JUSTICE AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2372
Country	:	US
Telephone Number	:	225-291-4282
Fax Number	:	225-291-7133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	12/18/2020

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