Individual
NICOLE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3707 E SOUTHERN AVE STE 2055, MESA, AZ 85206-6217
(605) 641-2972
Mailing address
3707 E SOUTHERN AVE STE 2055, MESA, AZ 85206-6217
(605) 641-2972
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LAC-19462
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LAC-19462
ARIZONA COUNSELOR LICENSE
AZ
Enumeration date
01/13/2022
Last updated
01/13/2022
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