Provider Demographics
NPI:1750048898
Name:WAGENER THERAPY PLC
Entity type:Organization
Organization Name:WAGENER THERAPY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDAL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGENER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:224-216-4209
Mailing Address - Street 1:4620 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3620
Mailing Address - Country:US
Mailing Address - Phone:224-216-4209
Mailing Address - Fax:
Practice Address - Street 1:6119 DEERE CREEK LN
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3402
Practice Address - Country:US
Practice Address - Phone:224-216-4209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1760038475OtherWELLMARK
IA1760038475OtherMIDLANDS CHOICE, INC.
IA1760038475OtherUNITED BEHAVIORAL HEALTH