Provider Demographics
NPI:1528265956
Name:WAGNER, MICHELLE DEAN (MS,LPC, BCPC)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:DEAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS,LPC, BCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 NORTHBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2532
Mailing Address - Country:US
Mailing Address - Phone:573-332-7889
Mailing Address - Fax:573-332-7889
Practice Address - Street 1:833 BROADWAY ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5515
Practice Address - Country:US
Practice Address - Phone:573-332-7889
Practice Address - Fax:573-332-7889
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001012922101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495017337Medicaid