Healthcare Provider Details

I. General information

NPI: 1588300180
Provider Name (Legal Business Name): CARLY A WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2022
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ROUND VALLEY DR STE 201
PARK CITY UT
84060-7549
US

IV. Provider business mailing address

2636 E STRINGHAM AVE APT A201
SALT LAKE CITY UT
84109-3948
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-7333
  • Fax:
Mailing address:
  • Phone: 941-301-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: