Basic Information
| Provider Information | |||||||||
| NPI: | 1821229352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGGONER | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25550 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | 2167650521 | ||||||||
| Practice Location | |||||||||
| Address1: | 25550 CHAGRIN BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167650500 | ||||||||
| FaxNumber: | 2167650521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2009 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1000347 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.