Provider Demographics
NPI:1336713080
Name:WAGNER, NATASHA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:5909 W AUTUMN VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-1294
Mailing Address - Country:US
Mailing Address - Phone:480-540-1099
Mailing Address - Fax:
Practice Address - Street 1:5909 W AUTUMN VISTA WAY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-1294
Practice Address - Country:US
Practice Address - Phone:480-540-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008764101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional