Provider Demographics
NPI:1295803476
Name:WAGNER, NICOLE S (PHD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26047 BYRON DR
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-1913
Mailing Address - Country:US
Mailing Address - Phone:216-548-5469
Mailing Address - Fax:
Practice Address - Street 1:29525 CHAGRIN BLVD STE 313
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-548-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6025103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWACP32401Medicare PIN