Provider Demographics
NPI:1306604343
Name:WAGNER, KELLI (LPC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15655 W ROOSEVELT ST STE 224
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9306
Mailing Address - Country:US
Mailing Address - Phone:928-683-1720
Mailing Address - Fax:
Practice Address - Street 1:15655 W ROOSEVELT ST STE 224
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9306
Practice Address - Country:US
Practice Address - Phone:928-683-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-20244101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health