| Doctor Name: | DR. KELLY CONDON WAGGONER |
| NPI Number: | 1275867418 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PSY.D. |
| License Number: | PSY 24570 |
| Business Practice Address: | 2200 Pacific Coast Hwy Ste 215 Hermosa Beach, CA - 902542701 |
| Business Phone Number: | 3105670456 |
| Business Fax Number: | |
| Mailing Address: | 2200 Pacific Coast Hwy Ste 215, HERMOSA BEACH |
| State: | CA |
| Postal Code: | 902542701 |
| Phone Number: | 3105670456 |
| Fax Number: | |
| NPI Enumeration Date: | 09/21/2009 |
| NPI Last Update Date: | 09/29/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | PSY 24570 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |