Healthcare Provider Details

I. General information

NPI: 1144129792
Provider Name (Legal Business Name): KIMBERLY LAYLA WAGNER M.A., LCHMCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAYLA WAGNER M.A., LCHMCA

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 11/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3508 MANFORD DR
DURHAM NC
27707-5143
US

IV. Provider business mailing address

3508 MANFORD DR
DURHAM NC
27707-5143
US

V. Phone/Fax

Practice location:
  • Phone: 919-605-4954
  • Fax:
Mailing address:
  • Phone: 919-605-4954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23656
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: