Provider Demographics
NPI:1548918832
Name:WAGONER, KATHRYN BEATRICE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BEATRICE
Last Name:WAGONER
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 1:1812 SAN JOSE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4136
Mailing Address - Country:US
Mailing Address - Phone:925-594-0786
Mailing Address - Fax:
Practice Address - Street 1:609 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6293
Practice Address - Country:US
Practice Address - Phone:707-399-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)