MEDICARE: TRICIA LYNN WAGNER LCPC, LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LAC1413	MT
2	101YM0800X	Mental Health Counselor	1379-LCPC	MT

General Provider Information

NPI Number	:	1730335282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRICIA LYNN WAGNER LCPC, LAC

Provider Business Mailing Address
First Line	:	1241 LUCCHESE ROAD
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59602
Country	:	US
Telephone Number	:	406-366-5934
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 W MAIN ST
Second Line	:	SUITE 318
City	:	LEWISTOWN
State	:	MT
Zip	:	59457-5703
Country	:	US
Telephone Number	:	406-366-5934
Fax Number	:

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

Provider Enumeration Date	:	08/15/2008
Last Update Date	:	04/06/2021

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