Healthcare Provider Details

I. General information

NPI: 1710287842
Provider Name (Legal Business Name): RAYMOND SAMUEL WAGSTAFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 S WYOMING ST
SALT LAKE CITY UT
84108-3237
US

IV. Provider business mailing address

1937 WYOMING ST
SALT LAKE CITY UT
84108-3237
US

V. Phone/Fax

Practice location:
  • Phone: 801-573-3213
  • Fax:
Mailing address:
  • Phone: 801-486-8635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8099256-6004
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: