Provider Demographics
NPI:1518460245
Name:WAGNER, BARBARA JO (LPC)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JO
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 SARA CT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-3200
Mailing Address - Country:US
Mailing Address - Phone:262-352-9406
Mailing Address - Fax:
Practice Address - Street 1:700 N PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1472
Practice Address - Country:US
Practice Address - Phone:262-342-5188
Practice Address - Fax:844-247-2735
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6503-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional