Provider Demographics
NPI:1962572230
Name:WAGSTAFF, ANNE BACON (LPC)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:BACON
Last Name:WAGSTAFF
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 1:7905 N MEADOWLARK WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-5041
Mailing Address - Country:US
Mailing Address - Phone:208-762-3979
Mailing Address - Fax:208-762-4419
Practice Address - Street 1:7905 N MEADOWLARK WAY
Practice Address - Street 2:SUITE C
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-762-3979
Practice Address - Fax:208-762-4419
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-779101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional