Provider Demographics
NPI:1144933425
Name:WAGGONER, RENEE FRANCES
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:FRANCES
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 1:229 TRAVERSE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9777
Mailing Address - Country:US
Mailing Address - Phone:248-459-0959
Mailing Address - Fax:
Practice Address - Street 1:16801 NEWBURGH RD STE 114
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:734-464-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician