Provider Demographics
NPI:1922593227
Name:WANNER, RAE
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:WANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2894
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-946-0991
Practice Address - Street 1:1300 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-9403
Practice Address - Country:US
Practice Address - Phone:501-208-5911
Practice Address - Fax:201-208-5912
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor