Healthcare Provider Details

I. General information

NPI: 1740113042
Provider Name (Legal Business Name): RACHAEL NICOLE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 KESTON DR
FAIRLESS HILLS PA
19030-3829
US

IV. Provider business mailing address

621 KESTON DR
FAIRLESS HILLS PA
19030-3829
US

V. Phone/Fax

Practice location:
  • Phone: 267-342-3503
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC002437
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: