Healthcare Provider Details

I. General information

NPI: 1649443805
Provider Name (Legal Business Name): PAMELA LOU WAGNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 STATESVILLE RD
CORNELIUS NC
28031-9353
US

IV. Provider business mailing address

20200 FLORAL LN
CORNELIUS NC
28031-9745
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-8005
  • Fax:
Mailing address:
  • Phone: 704-892-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6531
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: