Provider Demographics
NPI:1871904128
Name:WAGGONER, RACHEL
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 DETROIT AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3922
Mailing Address - Country:US
Mailing Address - Phone:216-543-5232
Mailing Address - Fax:
Practice Address - Street 1:14900 DETROIT AVE STE 206
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3922
Practice Address - Country:US
Practice Address - Phone:216-543-5232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1700304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health