Provider Demographics
NPI:1376727057
Name:WAGONER, CHERYL LEA (LMHC LICENSED MENTAL)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LEA
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LMHC LICENSED MENTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 BRANDON WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2381
Mailing Address - Country:US
Mailing Address - Phone:260-244-3427
Mailing Address - Fax:
Practice Address - Street 1:1308 BRANDON WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-2381
Practice Address - Country:US
Practice Address - Phone:260-244-3427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001832A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health