Provider Demographics
NPI:1003838582
Name:WAGNER, GAIL ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2028
Mailing Address - Country:US
Mailing Address - Phone:928-445-5027
Mailing Address - Fax:928-445-7071
Practice Address - Street 1:143 E MERRITT ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2028
Practice Address - Country:US
Practice Address - Phone:928-445-5027
Practice Address - Fax:928-445-7071
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC0404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11586734OtherCAQH