Provider Demographics
NPI:1609418631
Name:WAGNER, ALLISON JADE (LGPC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:JADE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2637
Mailing Address - Country:US
Mailing Address - Phone:304-671-5109
Mailing Address - Fax:
Practice Address - Street 1:124 N COURT ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6614
Practice Address - Country:US
Practice Address - Phone:301-304-7108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health