Logan Waggoner, BCBA

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

License

1-20-43093 Issued in IN

Practice address

4422 E State Blvd
Fort Wayne, IN 46815-6917

Phone

(855) 324-0885

Fax

(317) 520-8200

NPI assigned

Nov 5, 2020

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Practice roles

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.

• Children'S Autism Center, Inc

  • Developmental Disabilities Clinic/Center
  • Fort Wayne, IN
  • NPI 1215105663
  NPD (past)

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

{
    "created_epoch": "1604534400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664841600000",
    "number": "1962003962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3500 DEPAUW BLVD STE 3070",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462686135",
            "telephone_number": "855-324-0885",
            "fax_number": "317-520-8200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4422 E STATE BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468156917",
            "telephone_number": "855-324-0885",
            "fax_number": "317-520-8200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGGONER",
        "first_name": "LOGAN",
        "credential": "BCBA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-11-05",
        "last_updated": "2022-10-04",
        "certification_date": "2022-10-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "",
            "desc": "Behavior Analyst",
            "state": "IN",
            "license": "1-20-43093",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300045285",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Grace Wachenschwanz, OTD, OTR/L
• Kyler Wade
• Nicole Lynn Vesta Wade
• Sylvia Wade, MS ED.
• Kristine L. Waffle, MS, PT
• Logan Mitchell Wagler
• Amber Wagley
• Jonathan Wagley
• Mary E. Wagmeister, ANP
• Alexandria Wagner

• Behavior Analyst in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Behavior Analyst in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2022; 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.