Provider Demographics
NPI:1346916517
Name:WAGONBLOTT, HALEY ALYNN (LCPC)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:ALYNN
Last Name:WAGONBLOTT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7604 EICHER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-3004
Mailing Address - Country:US
Mailing Address - Phone:716-830-6258
Mailing Address - Fax:
Practice Address - Street 1:5001 COLLEGE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1618
Practice Address - Country:US
Practice Address - Phone:913-257-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLPC03956101YM0800X
KS03870101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health