MEDICARE: MORGAN WAGGONER LCPC

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	101YP2500X	Professional Counselor	180010947	IL

General Provider Information

NPI Number	:	1891220356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MORGAN WAGGONER LCPC

Provider Business Mailing Address
First Line	:	1434 W FARRAGUT AVENUE
Second Line	:	APT. 2C
City	:	CHICAGO
State	:	IL
Zip	:	60640
Country	:	US
Telephone Number	:	317-379-3266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1434 W FARRAGUT AVE
Second Line	:	APT. 2C
City	:	CHICAGO
State	:	IL
Zip	:	60640-2134
Country	:	US
Telephone Number	:	317-379-3266
Fax Number	:

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

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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