1033603527 NPI number — MRS. ABIGAIL RAE WAGNER LPC, LADC

Table of content: MRS. ABIGAIL RAE WAGNER LPC, LADC (NPI 1033603527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033603527 NPI number — MRS. ABIGAIL RAE WAGNER LPC, LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
ABIGAIL
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHARLSON
Provider Other First Name:
ABIGAIL
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LADC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033603527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 JEFFERSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIG LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55309-4667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-367-6080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55309-4667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-367-6080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  305134 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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