| Jerry Waggoner Lpc L.l.c. | |
|
1000 Lake Saint Louis Blvd Ste 260 Lake Saint Louis MO 63367-2924 | |
| (314) 994-9344 | |
| Not Available |
| Full Name | Jerry Waggoner Lpc L.l.c. |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1000 Lake Saint Louis Blvd Ste 260, Lake Saint Louis, Missouri |
| Authorized Official Name and Position | Jerry Waggoner (SOLE MEMBER) |
| Authorized Official Contact | 6366331980 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Jerry Waggoner Lpc L.l.c. 36 S Lake Dr Hillsboro MO 63050-4424 Ph: (636) 633-1980 | Jerry Waggoner Lpc L.l.c. 1000 Lake Saint Louis Blvd Ste 260 Lake Saint Louis MO 63367-2924 Ph: (314) 994-9344 |
| NPI Number | 1548546583 |
|---|---|
| Provider Enumeration Date | 10/21/2011 |
| Last Update Date | 10/21/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1548546583 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 001573 (Missouri) | Primary |
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