Healthcare Provider Details

I. General information

NPI: 1518050731
Provider Name (Legal Business Name): MARY ABIGAIL WAGNER LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5569 BROADCAST CT
LAKEWOOD RANCH FL
34240-8472
US

IV. Provider business mailing address

349 SEA GRAPE RD
VENICE FL
34293-1627
US

V. Phone/Fax

Practice location:
  • Phone: 941-254-4900
  • Fax: 941-355-2210
Mailing address:
  • Phone: 941-525-0318
  • Fax: 941-355-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: