Provider Demographics
NPI:1568794683
Name:RISOR-WAGNER, CAROLYN (MCP, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:RISOR-WAGNER
Suffix:
Gender:F
Credentials:MCP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 W OWEN K GARRIOTT RD STE F
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5653
Mailing Address - Country:US
Mailing Address - Phone:580-242-4673
Mailing Address - Fax:
Practice Address - Street 1:1625 W OWEN K GARRIOTT RD STE F
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5653
Practice Address - Country:US
Practice Address - Phone:580-242-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20-5274892Medicaid