MEDICARE: KILEIGH WAGENER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1013808336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KILEIGH WAGENER

Provider Business Mailing Address
First Line	:	467 W BROADWAY AVE
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-1402
Country	:	US
Telephone Number	:	952-208-1577
Fax Number	:

Provider Business Practice Location Address
First Line	:	467 W BROADWAY AVE
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-1402
Country	:	US
Telephone Number	:	952-208-1577
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2025
Last Update Date	:	07/14/2025

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Directions to “ KILEIGH WAGENER ” Practice Location

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