MEDICARE: SAMANTHA WAGNER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178016407	IL

General Provider Information

NPI Number	:	1003480922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA WAGNER LPC

Provider Business Mailing Address
First Line	:	63 BRITTANY DR
Second Line	:
City	:	OAKWOOD HILLS
State	:	IL
Zip	:	60013-6080
Country	:	US
Telephone Number	:	630-273-1524
Fax Number	:

Provider Business Practice Location Address
First Line	:	63 BRITTANY DR
Second Line	:
City	:	OAKWOOD HILLS
State	:	IL
Zip	:	60013-6080
Country	:	US
Telephone Number	:	630-273-1524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2021
Last Update Date	:	05/15/2021

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