Provider Demographics
NPI:1316612567
Name:WAGONER, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
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 1:4042 WALLOON LN APT 311
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-6626
Mailing Address - Country:US
Mailing Address - Phone:719-210-8194
Mailing Address - Fax:
Practice Address - Street 1:460 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1614
Practice Address - Country:US
Practice Address - Phone:719-210-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17154104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker