Provider Demographics
NPI:1164233003
Name:WAAGEN, TREVOR (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:
Last Name:WAAGEN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:DR
Other - First Name:LUCILLE
Other - Middle Name:
Other - Last Name:WAAGEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:3500 30TH AVE S APT 103
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5952
Mailing Address - Country:US
Mailing Address - Phone:406-478-3190
Mailing Address - Fax:
Practice Address - Street 1:501 N COLUMBIA RD RM 1300
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2817
Practice Address - Country:US
Practice Address - Phone:701-777-3745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND655103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling