Provider Demographics
NPI:1184268013
Name:WAGNER, CORRENA KAYE (MS)
Entity type:Individual
Prefix:MRS
First Name:CORRENA
Middle Name:KAYE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8290 COLLEGE PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5124
Mailing Address - Country:US
Mailing Address - Phone:239-240-0884
Mailing Address - Fax:
Practice Address - Street 1:8290 COLLEGE PKWY STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5124
Practice Address - Country:US
Practice Address - Phone:239-240-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)