| Doctor Name: | KIMBERLY A WAGGONER |
| NPI Number: | 1114954302 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MSW |
| License Number: | ISW00879 |
| Business Practice Address: | 1011 Veterans Memorial Pkwy East Providence, RI - 029155061 |
| Business Phone Number: | 4014321375 |
| Business Fax Number: | 4014321500 |
| Mailing Address: | 1011 Veterans Memorial Pkwy, EAST PROVIDENCE |
| State: | RI |
| Postal Code: | 029155061 |
| Phone Number: | 4014321284 |
| Fax Number: | 4014321509 |
| NPI Enumeration Date: | 06/26/2006 |
| NPI Last Update Date: | 01/07/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | ISW00879 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | RI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |