=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609676774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATIE WAGNER THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2025
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 ALGONQUIN RD # 1100
-----------------------------------------------------
City | ROLLING MEADOWS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60008-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-967-9108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1551 ALGONQUIN RD # 1100
-----------------------------------------------------
City | ROLLING MEADOWS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60008-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-967-9108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | KATHERINE WAGNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-967-9108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------