Healthcare Provider Details

I. General information

NPI: 1811711898
Provider Name (Legal Business Name): CAROLINE ROSE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 S OYSTER BAY RD
PLAINVIEW NY
11803-3310
US

IV. Provider business mailing address

199 N FOREST AVE
ROCKVILLE CENTRE NY
11570-3009
US

V. Phone/Fax

Practice location:
  • Phone: 516-888-4357
  • Fax:
Mailing address:
  • Phone: 917-620-9158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: