Provider Demographics
NPI:1255457479
Name:WAGNER, TIFFANY WYNN (LMFT)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:WYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 AIKEN PKWY
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2064
Mailing Address - Country:US
Mailing Address - Phone:919-412-7321
Mailing Address - Fax:
Practice Address - Street 1:602 E ACADEMY ST
Practice Address - Street 2:205
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2302
Practice Address - Country:US
Practice Address - Phone:919-412-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist