Derrick Wagoner, LPCC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

172294 Issued in KY

Practice address

104 Reynolds Rd
Glasgow, KY 42141-1177

Phone

(270) 678-4801

Fax

(270) 678-3866

NPI assigned

May 2, 2014

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2013

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

KW Consulting LLCGroup PAC ID 6901291756, 26 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• KW Consulting, LLC

  • Mental Health Counselor
  • Bowling Green, KY
  • NPI 1679127781
  Medicare reassignment Care Compare group NPD
• Alliance Counseling Associates

  • Mental Health Counselor
  • Glasgow, KY
  • NPI 1285938209
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1398988800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620777600000",
    "number": "1033529813",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 REYNOLDS RD",
            "city": "GLASGOW",
            "state": "KY",
            "postal_code": "421411177",
            "telephone_number": "270-678-4801",
            "fax_number": "270-678-3866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 REYNOLDS RD",
            "city": "GLASGOW",
            "state": "KY",
            "postal_code": "421411177",
            "telephone_number": "270-678-4801",
            "fax_number": "270-678-3866"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1048 Ashley St Ste 201",
            "address_purpose": "LOCATION",
            "city": "Bowling Green",
            "state": "KY",
            "postal_code": "421032449",
            "country_code": "US",
            "telephone_number": "270-904-6567",
            "fax_number": "270-904-6570",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1600 Scottsville Rd Ste 101",
            "address_purpose": "LOCATION",
            "city": "Bowling Green",
            "state": "KY",
            "postal_code": "421043217",
            "country_code": "US",
            "telephone_number": "270-904-6567",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1910 Lyda Ave",
            "address_purpose": "LOCATION",
            "city": "Bowling Green",
            "state": "KY",
            "postal_code": "421043326",
            "country_code": "US",
            "telephone_number": "270-904-6567",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGONER",
        "first_name": "DERRICK",
        "credential": "LPCC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-05-02",
        "last_updated": "2021-05-12",
        "certification_date": "2021-05-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "KY",
            "license": "1839",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "KY",
            "license": "172294",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eric Todd Vessels, M.D.
• Michele Grace Vincent, APRN
• W. Craig Tyree, MD, PLC
• Wagner & Wagner PSC
• Ronald T. Wagner, O. D.
• Irfan Waheed, M.D.
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP
• Amanda Moore Walden, PHARM.D.
• Walgreen Co

• Mental Health Counselor in Glasgow, KY
• Providers in Glasgow, KY by specialty
• Mental Health Counselor in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.