Provider Demographics
NPI:1497982375
Name:WAGNER, MARK WOLF (MA, PCC-S)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WOLF
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MA, PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7159
Mailing Address - Country:US
Mailing Address - Phone:330-433-2390
Mailing Address - Fax:330-433-2391
Practice Address - Street 1:7300 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7159
Practice Address - Country:US
Practice Address - Phone:330-433-2390
Practice Address - Fax:330-433-2391
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0004085101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional