Provider Demographics
NPI:1922361393
Name:WAGUESPACK, RICHARD S JR (BTH, LCSW)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:S
Last Name:WAGUESPACK
Suffix:JR
Gender:M
Credentials:BTH, LCSW
Other - Prefix:
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Mailing Address - Street 1:303 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CORDELL
Mailing Address - State:OK
Mailing Address - Zip Code:73632-4229
Mailing Address - Country:US
Mailing Address - Phone:580-500-8050
Mailing Address - Fax:888-344-9087
Practice Address - Street 1:603 W GARY BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-2715
Practice Address - Country:US
Practice Address - Phone:580-500-8050
Practice Address - Fax:888-344-9087
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK43891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200506970-BMedicaid
TX1177115-05Medicaid