Provider Demographics
NPI:1548611387
Name:WAGNER, MIRACLE (LPC)
Entity type:Individual
Prefix:MRS
First Name:MIRACLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201593
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-1593
Mailing Address - Country:US
Mailing Address - Phone:817-264-6048
Mailing Address - Fax:
Practice Address - Street 1:805 WASHINGTON DR STE D
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-2528
Practice Address - Country:US
Practice Address - Phone:817-264-6048
Practice Address - Fax:817-549-9755
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
TX72494101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360855601Medicaid