Provider Demographics
NPI:1477015881
Name:WAGONER, NICOLE (LPCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 MIDDLE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-2101
Mailing Address - Country:US
Mailing Address - Phone:910-759-5959
Mailing Address - Fax:
Practice Address - Street 1:233 MIDDLE ST STE 105
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-2101
Practice Address - Country:US
Practice Address - Phone:910-759-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14357101YM0800X
NC14357251S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295468742Medicaid
NC1477015881Medicaid