Provider Demographics
NPI:1760752232
Name:WAGNER, EMILY L (LPC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:L
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 1:4141 B ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5941
Mailing Address - Country:US
Mailing Address - Phone:907-268-8484
Mailing Address - Fax:855-456-2799
Practice Address - Street 1:4441 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5910
Practice Address - Country:US
Practice Address - Phone:907-729-8565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101194101YP2500X
MO2011019681101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional