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General NPI Number Information
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NPI Number | 1285275446
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Entity Type | Individual
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Provider Name | DIANNE WAGONER
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Gender | Female
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Dates
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Enumeration Date | 09/30/2019
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Last Update Date | 09/30/2019
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Provider Practice Location Address
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Address Line | 200 E MAIN ST
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City | ROCKAWAY
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State | NJ
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Zip | 07866-3614
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Country | US
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Telephone | 973-229-3198
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Fax |
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Provider Business Mailing Address
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Address Line | 8 RESERVOIR RD
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City | LAKE HOPATCONG
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State | NJ
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Zip | 07849-1712
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Country | US
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Telephone | 973-663-1303
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 37CA000098200
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License Number State | NJ
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