Provider Demographics
NPI:1730057142
Name:WAGNER, LISA M (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 N JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-4822
Mailing Address - Country:US
Mailing Address - Phone:630-995-5770
Mailing Address - Fax:
Practice Address - Street 1:1300 IROQUOIS AVE STE 160
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1143
Practice Address - Country:US
Practice Address - Phone:630-447-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019011101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health