Kelly Waggoner, LPCC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

CCHM0207621 Issued in NM

Practice address

5165 Bowers Brook Dr SW
Lilburn, GA 30047-5172

Phone

(505) 695-1613

NPI assigned

Jan 13, 2014

Last updated

Jul 20, 2020By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: kellyhaynes@tdh.allscriptsdirect.net

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

• Teladoc Health Medical Group, P.a.

  • Family Medicine Physician
  • Lewisville, TX
  • NPI 1245403567

  Mental Health

  NPD

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

{
    "created_epoch": "1389571200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1595203200000",
    "number": "1730501511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5165 BOWERS BROOK DR SW",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300475172",
            "telephone_number": "505-695-1613"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5165 BOWERS BROOK DR SW",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300475172",
            "telephone_number": "505-695-1613"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "11005 Spain Rd NE Ste 21",
            "address_purpose": "LOCATION",
            "city": "Albuquerque",
            "state": "NM",
            "postal_code": "871111871",
            "country_code": "US",
            "telephone_number": "505-695-1613",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WAGGONER",
        "first_name": "KELLY",
        "name_prefix": "Mrs.",
        "credential": "LPCC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2014-01-13",
        "last_updated": "2020-07-20",
        "certification_date": "2020-07-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NM",
            "license": "CCHM0207621",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Sync",
            "affiliation": "N",
            "address_1": "5165 Bowers Brook Dr SW",
            "city": "Lilburn",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300475172",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Mental Health Counselor in Lilburn, GA
• Providers in Lilburn, GA by specialty
• Mental Health Counselor in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.