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General NPI Number Information
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NPI Number | 1790310860
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Entity Type | Individual
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Provider Name | EDWARD T WAGNER III LPC
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Gender | Male
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Dates
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Enumeration Date | 03/09/2020
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Last Update Date | 11/29/2024
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Provider Practice Location Address
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Address Line | 1831 SWAMP PIKE STE 100
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City | GILBERTSVILLE
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State | PA
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Zip | 19525-8927
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Country | US
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Telephone | 610-484-0736
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Fax |
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Provider Business Mailing Address
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Address Line | 2583 CRABAPPLE CT
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City | GILBERTSVILLE
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State | PA
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Zip | 19525-8839
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Country | US
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Telephone | 610-850-3859
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PC012234
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License Number State | PA
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