Healthcare Provider Details

I. General information

NPI: 1811828916
Provider Name (Legal Business Name): MICHAEL CHRISTOPHER WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 FIFTH AVE
CHARDON OH
44024-1088
US

IV. Provider business mailing address

521 FIFTH AVE
CHARDON OH
44024-1088
US

V. Phone/Fax

Practice location:
  • Phone: 440-286-1553
  • Fax:
Mailing address:
  • Phone: 440-286-1553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2309598
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: