Basic Information
| Provider Information | |||||||||
| NPI: | 1790940286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGGONER | ||||||||
| FirstName: | LINDSEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56625 E 130 ROAD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189192614 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 HARBER ROAD | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864434 | ||||||||
| FaxNumber: | 9187864435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.