MEDICARE: BENJAMIN KENT WAGNER LPC-MHSP

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	101YP2500X	Professional Counselor	7325
2	101YM0800X	Mental Health Counselor	7325	TN

General Provider Information

NPI Number	:	1255163283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN KENT WAGNER LPC-MHSP

Provider Business Mailing Address
First Line	:	1216 SEMINOLE DR APT 5
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-7154
Country	:	US
Telephone Number	:	423-470-4683
Fax Number	:

Provider Business Practice Location Address
First Line	:	4012 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-2028
Country	:	US
Telephone Number	:	423-430-9687
Fax Number	:

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

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	08/19/2024

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