MEDICARE: ANNE BACON WAGSTAFF LPC

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	LPC-779	ID

General Provider Information

NPI Number	:	1962572230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE BACON WAGSTAFF LPC

Provider Business Mailing Address
First Line	:	7905 N MEADOWLARK WAY
Second Line	:	SUITE C
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-5041
Country	:	US
Telephone Number	:	208-762-3979
Fax Number	:	208-762-4419

Provider Business Practice Location Address
First Line	:	7905 N MEADOWLARK WAY
Second Line	:	SUITE C
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-5041
Country	:	US
Telephone Number	:	208-762-3979
Fax Number	:	208-762-4419

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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