Provider Demographics
NPI:1144578238
Name:WAGNER, NATHANIEL JACOB (PHD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:JACOB
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8256 S CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5014
Mailing Address - Country:US
Mailing Address - Phone:812-370-0370
Mailing Address - Fax:
Practice Address - Street 1:8256 S CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5014
Practice Address - Country:US
Practice Address - Phone:812-370-0370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health