Healthcare Provider Details

I. General information

NPI: 1376147157
Provider Name (Legal Business Name): KATHERINE MAUREEN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 ALGONQUIN RD # 1100
ROLLING MEADOWS IL
60008-4104
US

IV. Provider business mailing address

1551 ALGONQUIN RD # 1100
ROLLING MEADOWS IL
60008-4104
US

V. Phone/Fax

Practice location:
  • Phone: 773-967-9108
  • Fax:
Mailing address:
  • Phone: 773-967-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: