Healthcare Provider Details

I. General information

NPI: 1184548091
Provider Name (Legal Business Name): WENDY WAGENER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N SHORE DR
WAVERLY MN
55390-5517
US

IV. Provider business mailing address

550 MAIN STREET SUITE 190
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 320-543-5686
  • Fax:
Mailing address:
  • Phone: 320-543-5686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301570
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: