Healthcare Provider Details

I. General information

NPI: 1831028174
Provider Name (Legal Business Name): CORILYN ASHLEY WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 GRAND AVE
SAINT PAUL MN
55105-2629
US

IV. Provider business mailing address

1129 GRAND AVE
SAINT PAUL MN
55105-2629
US

V. Phone/Fax

Practice location:
  • Phone: 612-619-7611
  • Fax: 651-964-4748
Mailing address:
  • Phone: 651-641-0177
  • Fax: 651-641-8635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5588
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: