| Doctor Name: | DERRICK WAGONER |
| NPI Number: | 1033529813 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LPCA |
| License Number: | 1839 |
| Business Practice Address: | 1048 Ashley St Ste 201 Bowling Green, KY - 421032449 |
| Business Phone Number: | 2709046567 |
| Business Fax Number: | 2709046570 |
| Mailing Address: | 104 Reynolds Rd, GLASGOW |
| State: | KY |
| Postal Code: | 421411177 |
| Phone Number: | 2706784801 |
| Fax Number: | 2706783866 |
| NPI Enumeration Date: | 05/02/2014 |
| NPI Last Update Date: | 05/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 1839 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |