Provider Demographics
NPI:1033603527
Name:WAGNER, ABIGAIL RAE (LPC, LADC)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:RAE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:RAE
Other - Last Name:CHARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:207 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-4667
Mailing Address - Country:US
Mailing Address - Phone:763-367-6080
Mailing Address - Fax:
Practice Address - Street 1:207 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4667
Practice Address - Country:US
Practice Address - Phone:763-367-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305134101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)