MEDICARE: RAYMOND SAMUEL WAGSTAFF

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
2	101YM0800X	Mental Health Counselor	8099256-6004	UT
3	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1710287842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND SAMUEL WAGSTAFF

Provider Business Mailing Address
First Line	:	1937 WYOMING ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3237
Country	:	US
Telephone Number	:	801-486-8635
Fax Number	:

Provider Business Practice Location Address
First Line	:	1937 S WYOMING ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3237
Country	:	US
Telephone Number	:	801-573-3213
Fax Number	:

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

Provider Enumeration Date	:	10/22/2010
Last Update Date	:	06/30/2026

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