Individual
DERRICK WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPCC
Contact information
Practice address
104 REYNOLDS RD, GLASGOW, KY 42141-1177
(270) 678-4801
(270) 678-3866
Mailing address
104 REYNOLDS RD, GLASGOW, KY 42141-1177
(270) 678-4801
(270) 678-3866
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
172294
KY
101YP2500X
Professional Counselor
1839
KY
Other
Enumeration date
05/02/2014
Last updated
05/12/2021
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