Provider Demographics
NPI:1962706176
Name:WAGNER, CYNTHIA (LPC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
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 1:1300 S CLEVELAND ST APT 361
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-4848
Mailing Address - Country:US
Mailing Address - Phone:703-597-6928
Mailing Address - Fax:
Practice Address - Street 1:3801 FAIRFAX DR STE 61
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1762
Practice Address - Country:US
Practice Address - Phone:571-523-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC14138101YP2500X
VA0701005467101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional