Provider Demographics
NPI:1144360868
Name:WEGNER, CHERYL L (LADC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:WEGNER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68826-9747
Mailing Address - Country:US
Mailing Address - Phone:308-946-3269
Mailing Address - Fax:
Practice Address - Street 1:2116 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4645
Practice Address - Country:US
Practice Address - Phone:308-398-5427
Practice Address - Fax:308-398-5404
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NELADC-063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NELADC-063OtherLICENSE ALCOHOL DRUG COUN