Provider Demographics
NPI:1760151153
Name:CHERYL WAGONER LMHC PRIVATE PRACTICE
Entity Type:Organization
Organization Name:CHERYL WAGONER LMHC PRIVATE PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-244-3427
Mailing Address - Street 1:6450 E MCGUIRE RD
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-9341
Mailing Address - Country:US
Mailing Address - Phone:260-244-3427
Mailing Address - Fax:
Practice Address - Street 1:6450 E MCGUIRE RD
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-9341
Practice Address - Country:US
Practice Address - Phone:260-244-3427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty