Provider Demographics
NPI:1669039319
Name:WAGENHOFFER, MICHELLE (MA, LBS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAGENHOFFER
Suffix:
Gender:F
Credentials:MA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 JASMINE CT
Mailing Address - Street 2:
Mailing Address - City:ZIEGLERVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19492-9726
Mailing Address - Country:US
Mailing Address - Phone:267-625-1599
Mailing Address - Fax:
Practice Address - Street 1:4462 BUCK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-4182
Practice Address - Country:US
Practice Address - Phone:215-527-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003142103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst