MEDICARE: MS. MARGI LYNN WAGNER-FARLEY

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		IL

General Provider Information

NPI Number	:	1659563096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARGI LYNN WAGNER-FARLEY

Provider Business Mailing Address
First Line	:	3120 STATE ST STE A
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2204
Country	:	US
Telephone Number	:	618-875-0673
Fax Number	:	618-875-0861

Provider Business Practice Location Address
First Line	:	3120 STATE ST STE A
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62205-2204
Country	:	US
Telephone Number	:	618-875-0673
Fax Number	:	618-875-0861

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	08/09/2007

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