Provider Demographics
NPI:1780074567
Name:WAGNER, SHILO ALLENE (MS MHC)
Entity type:Individual
Prefix:
First Name:SHILO
Middle Name:ALLENE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10156 N ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34434-3104
Mailing Address - Country:US
Mailing Address - Phone:352-476-4311
Mailing Address - Fax:
Practice Address - Street 1:10156 N ACADEMY DR
Practice Address - Street 2:
Practice Address - City:CITRUS SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34434-3104
Practice Address - Country:US
Practice Address - Phone:352-476-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health