Provider Demographics
NPI:1407655509
Name:WAGNER COUNSELING PLLC SAMANTHA WAGNER SOLE MBR
Entity type:Organization
Organization Name:WAGNER COUNSELING PLLC SAMANTHA WAGNER SOLE MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-439-2321
Mailing Address - Street 1:112 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4051
Mailing Address - Country:US
Mailing Address - Phone:608-313-4655
Mailing Address - Fax:
Practice Address - Street 1:112 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4051
Practice Address - Country:US
Practice Address - Phone:608-313-4655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty