Provider Demographics
NPI:1174618813
Name:WAGGENER, KRISTI DEANNA (LAC)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:DEANNA
Last Name:WAGGENER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 HIGHWAY 115
Mailing Address - Street 2:
Mailing Address - City:DEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71328
Mailing Address - Country:US
Mailing Address - Phone:318-466-1088
Mailing Address - Fax:
Practice Address - Street 1:UNIT 6 MEADOW LANE
Practice Address - Street 2:CENTRAL LA STATE HOSPITAL - RED RIVER TREATMENT CENTER
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-484-6609
Practice Address - Fax:318-487-5703
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health