=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407655509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAGNER COUNSELING PLLC SAMANTHA WAGNER SOLE MBR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 N 2ND ST
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-313-4655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 N 2ND ST
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-313-4655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | PATTY NUNEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-439-2321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------