Individual
COREY WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1817 NE 6TH AVE, PORTLAND, OR 97212-3960
(503) 719-7985
Mailing address
1817 NE 6TH AVE, PORTLAND, OR 97212-3960
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
25-CRM-4021
OR
Other
Enumeration date
01/16/2025
Last updated
01/16/2025
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