Healthcare Provider Details

I. General information

NPI: 1750875704
Provider Name (Legal Business Name): NATHANAEL WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE STE C
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

1157 TREEWAY NW
SPARTA MI
49345-8240
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-7106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: