Individual
CHELSAE WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
—
—
3104A0630X
Assisted Living Facility (Behavioral Disturbances)
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
480CC0877
DRIVERS LICENSE
IA
Enumeration date
03/24/2022
Last updated
03/24/2022
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