Provider Demographics
NPI:1841733474
Name:WAGNER, JOY (MFT)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:WI
Mailing Address - Zip Code:53039-1320
Mailing Address - Country:US
Mailing Address - Phone:920-214-3733
Mailing Address - Fax:
Practice Address - Street 1:150 MILLER ST
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-1320
Practice Address - Country:US
Practice Address - Phone:920-214-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1245124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist