Provider Demographics
NPI:1316658974
Name:WAGGONER, SAMUEL RUSSELL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RUSSELL
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1831
Mailing Address - Country:US
Mailing Address - Phone:503-238-5203
Mailing Address - Fax:
Practice Address - Street 1:2727 NE FLANDERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3159
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-22-1492101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)