Provider Demographics
NPI:1003480922
Name:WAGNER, SAMANTHA (LPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BRITTANY DR
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60013-6080
Mailing Address - Country:US
Mailing Address - Phone:630-273-1524
Mailing Address - Fax:
Practice Address - Street 1:63 BRITTANY DR
Practice Address - Street 2:
Practice Address - City:OAKWOOD HILLS
Practice Address - State:IL
Practice Address - Zip Code:60013-6080
Practice Address - Country:US
Practice Address - Phone:630-273-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178016407101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional