Healthcare Provider Details

I. General information

NPI: 1790814937
Provider Name (Legal Business Name): NICOLE L WAGSTROM PCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 RED ROBIN DR N
XENIA OH
45385-9915
US

IV. Provider business mailing address

2000 RED ROBIN DR N
XENIA OH
45385-9915
US

V. Phone/Fax

Practice location:
  • Phone: 937-718-3317
  • Fax:
Mailing address:
  • Phone: 937-718-3317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8377
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: