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General NPI Number Information
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NPI Number | 1932664075
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Entity Type | Individual
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Provider Name | MELISSA R WAGNER LCAS
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Gender | Female
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Dates
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Enumeration Date | 02/03/2019
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Last Update Date | 02/08/2025
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Provider Practice Location Address
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Address Line | 310 W THIRD AVE
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City | GASTONIA
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State | NC
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Zip | 28052-4004
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Country | US
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Telephone | 704-868-8644
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Fax |
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Provider Business Mailing Address
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Address Line | 2015 DONEGAL CT
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City | GASTONIA
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State | NC
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Zip | 28054-6702
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Country | US
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Telephone | 980-474-0117
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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 | 25261
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License Number State | NC
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