Provider Demographics
NPI:1992833297
Name:WAGNER, DANIELLE CARRIE (LCGC)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:CARRIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CONTINENTAL LN
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4606
Mailing Address - Country:US
Mailing Address - Phone:609-206-0210
Mailing Address - Fax:
Practice Address - Street 1:1 S PENN SQ
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-3400
Practice Address - Country:US
Practice Address - Phone:215-873-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2002350170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS