Provider Demographics
NPI:1750513727
Name:WAGNER, KELLY JEAN (LMHC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:230 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2411
Mailing Address - Country:US
Mailing Address - Phone:515-573-3138
Mailing Address - Fax:515-573-3130
Practice Address - Street 1:4301 SERGEANT RD
Practice Address - Street 2:STE 203
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4710
Practice Address - Country:US
Practice Address - Phone:712-276-9000
Practice Address - Fax:712-276-4917
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00850101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health