Provider Demographics
NPI:1073640595
Name:WAGNER, KARI SUE (MA)
Entity Type:Individual
Prefix:MS
First Name:KARI
Middle Name:SUE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:KARI
Other - Middle Name:SUE
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-4142
Mailing Address - Country:US
Mailing Address - Phone:224-366-1517
Mailing Address - Fax:
Practice Address - Street 1:201 KENDALL DRIVE
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052
Practice Address - Country:US
Practice Address - Phone:719-336-7501
Practice Address - Fax:719-336-7453
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
53344OtherNCC