Provider Demographics
NPI:1619674017
Name:WAGAR, MICHELLE MEGAN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MEGAN
Last Name:WAGAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6770 DIXIE HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2088
Mailing Address - Country:US
Mailing Address - Phone:248-922-7726
Mailing Address - Fax:
Practice Address - Street 1:6770 DIXIE HWY STE 103
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2088
Practice Address - Country:US
Practice Address - Phone:248-922-7726
Practice Address - Fax:248-856-1492
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022786103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling