Individual
ELIZABETH WAGONER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
25 EXECUTIVE DR STE F, LAFAYETTE, IN 47905-4880
(217) 504-0131
Mailing address
25 EXECUTIVE DR STE F, LAFAYETTE, IN 47905-4880
(217) 504-0131
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
99135905A
IN
Other
Enumeration date
04/16/2026
Last updated
04/16/2026
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