Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 178016407 | IL |
NPI | 1003480922 |
---|---|
Provider Name | Samantha Wagner |
First Address | Oakwood Hills, IL 60013-6080 |
Second Address | Oakwood Hills, IL 60013-6080 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2021 |
Last Update Date | 15/05/2021 |