Provider Demographics
NPI:1285275446
Name:WAGONER, DIANNE
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 RESERVOIR RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07849-1712
Mailing Address - Country:US
Mailing Address - Phone:973-663-1303
Mailing Address - Fax:
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3614
Practice Address - Country:US
Practice Address - Phone:973-229-3198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37CA000098200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)