Individual
KIMBERLY A WAGGONER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MSW
Contact information
Practice address
400 MASSASOIT AVE STE 101, EAST PROVIDENCE, RI 02914-2017
(401) 612-7693
(401) 432-1500
Mailing address
400 MASSASOIT AVE STE 101, EAST PROVIDENCE, RI 02914-2017
(401) 612-7693
(401) 432-1509
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
ISW00879
RI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
31025-9
BLUE CROSS
RI
01
—
413014
BLUE CHIP
RI
01
—
62-23076
UNITED BEHAVIORAL HEALTH
RI
05
—
KW10798
—
RI
Enumeration date
06/26/2006
Last updated
08/28/2021
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