Provider Demographics
NPI:1477386654
Name:WAGNER, DANIELLE BROOKE (LCMHCA)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:BROOKE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 S BRIGHTLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4385
Mailing Address - Country:US
Mailing Address - Phone:919-300-4315
Mailing Address - Fax:919-205-1512
Practice Address - Street 1:831 S BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4385
Practice Address - Country:US
Practice Address - Phone:919-300-4315
Practice Address - Fax:919-205-1512
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional