Provider Demographics
NPI:1942507231
Name:WAGNER-MARTIN, ERIKA J (MS, NCC)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:J
Last Name:WAGNER-MARTIN
Suffix:
Gender:F
Credentials:MS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 SCHOOL DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7356
Mailing Address - Country:US
Mailing Address - Phone:414-839-7213
Mailing Address - Fax:
Practice Address - Street 1:325 FOREST GROVE DR
Practice Address - Street 2:STE 201
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3894
Practice Address - Country:US
Practice Address - Phone:262-691-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI635-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health