Provider Demographics
NPI:1003325416
Name:WAGNER, PHYLISS (LPCC)
Entity type:Individual
Prefix:
First Name:PHYLISS
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1622
Mailing Address - Country:US
Mailing Address - Phone:440-989-4987
Mailing Address - Fax:440-296-2050
Practice Address - Street 1:842 CORPORATE WAY STE 850
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1537
Practice Address - Country:US
Practice Address - Phone:440-296-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2001993101YP2500X
OHCDCA.164771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.164771OtherLICENSE