Active NPI
Kimberly A Waggoner, MSW
- Clinical Social Worker
- East Providence, RI
National Provider Identifier
1114954302
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- ISW00879
- Practice address
- 400 Massasoit Ave Ste 101
East Providence, RI 02914-2017 - Phone
- (401) 612-7693
- Fax
- (401) 432-1500
- NPI assigned
- Jun 26, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | ISW00879 | RI | Primary |
Addresses
Primary practice location
400 Massasoit Ave Ste 101
East Providence, RI 02914-2017
Mailing address
400 Massasoit Ave Ste 101
East Providence, RI 02914-2017
Phone (401) 612-7693
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| KW10798 | Medicaid | RI | |
| 62-23076 | Other | RI | UNITED BEHAVIORAL HEALTH |
| 413014 | Other | RI | BLUE CHIP |
| 31025-9 | Other | RI | BLUE CROSS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in RI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20140210001197 | RI | Practitioner - Clinical Social Worker | 4789813932 | Practice locations: Providence, RI |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ISW00879 | RI | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1151280000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1630108800000",
"number": "1114954302",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "400 MASSASOIT AVE STE 101",
"city": "EAST PROVIDENCE",
"state": "RI",
"postal_code": "029142017",
"telephone_number": "401-612-7693",
"fax_number": "401-432-1509"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "400 MASSASOIT AVE STE 101",
"city": "EAST PROVIDENCE",
"state": "RI",
"postal_code": "029142017",
"telephone_number": "401-612-7693",
"fax_number": "401-432-1500"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGGONER",
"first_name": "KIMBERLY",
"middle_name": "A",
"credential": "MSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-06-26",
"last_updated": "2021-08-28",
"certification_date": "2021-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "RI",
"license": "ISW00879",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "KW10798",
"state": "RI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED BEHAVIORAL HEALTH",
"identifier": "62-23076",
"state": "RI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CHIP",
"identifier": "413014",
"state": "RI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS",
"identifier": "31025-9",
"state": "RI"
}
],
"endpoints": [],
"other_names": []
}Other providers in East Providence, RI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.