Provider Demographics
NPI:1518537745
Name:WAGNER, COURTNEY CIMONE (LMHC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CIMONE
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 1:201 W 24TH ST UNIT 222
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1364
Mailing Address - Country:US
Mailing Address - Phone:757-310-3039
Mailing Address - Fax:
Practice Address - Street 1:442 AMBER ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5284
Practice Address - Country:US
Practice Address - Phone:757-310-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional