Provider Demographics
NPI:1598379752
Name:WAGNER, MADISON GABRIELLE (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:GABRIELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ESTHERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:51334-0036
Mailing Address - Country:US
Mailing Address - Phone:800-592-0180
Mailing Address - Fax:
Practice Address - Street 1:1820 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ESTHERVILLE
Practice Address - State:IA
Practice Address - Zip Code:51334-2409
Practice Address - Country:US
Practice Address - Phone:800-592-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093041101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health