MEDICARE: MRS. CHERYL LEA WAGONER LMHC LICENSED MENTAL

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	101YM0800X	Mental Health Counselor	39001832A	IN

General Provider Information

NPI Number	:	1376727057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERYL LEA WAGONER LMHC LICENSED MENTAL

Provider Business Mailing Address
First Line	:	1308 BRANDON WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-2381
Country	:	US
Telephone Number	:	260-244-3427
Fax Number	:

Provider Business Practice Location Address
First Line	:	1308 BRANDON WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-2381
Country	:	US
Telephone Number	:	260-244-3427
Fax Number	:

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

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	11/18/2009

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