Provider Demographics
NPI:1780445742
Name:WAGNER, MELISSA JOY (LPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JOY
Other - Last Name:SOGAVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:4745 MAIN ST STE 207
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1758
Mailing Address - Country:US
Mailing Address - Phone:630-442-1895
Mailing Address - Fax:
Practice Address - Street 1:4745 MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1758
Practice Address - Country:US
Practice Address - Phone:630-442-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019235221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist