Healthcare Provider Details

I. General information

NPI: 1790691194
Provider Name (Legal Business Name): LAURA WAGNER LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 CHARLEVOIX RD STE 306
PETOSKEY MI
49770-8423
US

IV. Provider business mailing address

900 EMMET ST APT 313
PETOSKEY MI
49770-2990
US

V. Phone/Fax

Practice location:
  • Phone: 231-442-0886
  • Fax:
Mailing address:
  • Phone: 269-903-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851121709
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: