Individual
BENTON WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
418 N RIVER ST, HAILEY, ID 83333-8513
(612) 247-9768
Mailing address
PO BOX 424, FAIRFIELD, ID 83327-0424
(612) 247-9768
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LCPC-6760
ID
Other
Enumeration date
04/01/2014
Last updated
03/05/2024
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