Provider Demographics
NPI:1154116820
Name:WAGONER, FREDERICK RANSON (LPCA)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:RANSON
Last Name:WAGONER
Suffix:
Gender:
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 ROYDON DR APT 1302
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77034-4877
Mailing Address - Country:US
Mailing Address - Phone:865-567-5023
Mailing Address - Fax:
Practice Address - Street 1:12801 ROYDON DR APT 1302
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-4877
Practice Address - Country:US
Practice Address - Phone:865-567-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91801101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health