Provider Demographics
NPI:1467986141
Name:WAGNER, CAROLYN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ELMORE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3520
Mailing Address - Country:US
Mailing Address - Phone:847-728-8148
Mailing Address - Fax:
Practice Address - Street 1:1159 WILMETTE AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2649
Practice Address - Country:US
Practice Address - Phone:847-728-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008548101YP2500X
IL180.013022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional