Provider Demographics
NPI:1457654808
Name:WAGNER, KRISTIN M (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11210 FLATIRON DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-9618
Mailing Address - Country:US
Mailing Address - Phone:303-882-2755
Mailing Address - Fax:
Practice Address - Street 1:1650 38TH ST STE 100E
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2624
Practice Address - Country:US
Practice Address - Phone:720-257-9416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0012533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional