Healthcare Provider Details

I. General information

NPI: 1417489196
Provider Name (Legal Business Name): ALISSA WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 FLEISCHMANN WAY
CARSON CITY NV
89703-2995
US

IV. Provider business mailing address

1955 OPPIO ST
SPARKS NV
89431-1970
US

V. Phone/Fax

Practice location:
  • Phone: 775-445-8905
  • Fax:
Mailing address:
  • Phone: 925-577-8532
  • Fax: 925-577-8532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIC-2382
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number07845-S
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: