Provider Demographics
NPI:1518050731
Name:WAGNER, MARY ABIGAIL (LMHC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ABIGAIL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 SEA GRAPE RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1627
Mailing Address - Country:US
Mailing Address - Phone:941-525-0318
Mailing Address - Fax:941-355-2210
Practice Address - Street 1:5569 BROADCAST CT
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8472
Practice Address - Country:US
Practice Address - Phone:941-254-4900
Practice Address - Fax:941-355-2210
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL757008200Medicaid