Provider Demographics
NPI:1790814937
Name:WAGSTROM, NICOLE L (PCC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:WAGSTROM
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 HILLSDALE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-5672
Mailing Address - Country:US
Mailing Address - Phone:937-429-8719
Mailing Address - Fax:
Practice Address - Street 1:801 SPACE DRIVE
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-7162
Practice Address - Country:US
Practice Address - Phone:937-431-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional