Provider Demographics
NPI:1881903375
Name:WAGNER, AMANDA (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 PRESIDENT ST
Mailing Address - Street 2:MSC 861
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8150
Mailing Address - Country:US
Mailing Address - Phone:843-792-0484
Mailing Address - Fax:
Practice Address - Street 1:125 DOUGHTY ST
Practice Address - Street 2:SUITE 190
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5736
Practice Address - Country:US
Practice Address - Phone:843-792-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5209101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional