Provider Demographics
NPI:1003566985
Name:WAGNER, CHELSAE
Entity Type:Individual
Prefix:
First Name:CHELSAE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 COUNTY ROAD E45
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:IA
Mailing Address - Zip Code:52362-7514
Mailing Address - Country:US
Mailing Address - Phone:319-929-8702
Mailing Address - Fax:
Practice Address - Street 1:8005 COUNTY ROAD E45
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:IA
Practice Address - Zip Code:52362-7514
Practice Address - Country:US
Practice Address - Phone:319-929-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA480CC0877OtherDRIVERS LICENSE