Healthcare Provider Details

I. General information

NPI: 1538542246
Provider Name (Legal Business Name): LORI ANN WAGNER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11334 86TH AVE N
MAPLE GROVE MN
55369-4528
US

IV. Provider business mailing address

615 1ST AVE NE STE 310
MINNEAPOLIS MN
55413-2419
US

V. Phone/Fax

Practice location:
  • Phone: 763-255-2125
  • Fax: 763-255-2126
Mailing address:
  • Phone: 612-436-0295
  • Fax: 612-436-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC01011
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC01011
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: