Provider Demographics
NPI:1194233270
Name:WAGNER, CHAVONNE (LPC)
Entity type:Individual
Prefix:
First Name:CHAVONNE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DANIELLE CT
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-5014
Mailing Address - Country:US
Mailing Address - Phone:513-499-5266
Mailing Address - Fax:
Practice Address - Street 1:1100 EATON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1403
Practice Address - Country:US
Practice Address - Phone:513-499-5266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2303947101YP2500X
OHLICDC.162685101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)