Healthcare Provider Details

I. General information

NPI: 1144098518
Provider Name (Legal Business Name): MICHAEL J. WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/15/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DRIVER STE 102
SANTA FE NM
87507
US

IV. Provider business mailing address

11 ROSEWOOD DR
HOWELL NJ
07731-3414
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9437
  • Fax: 505-930-5427
Mailing address:
  • Phone: 732-966-0595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: