Carolyn Wagner, MA, LPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

180.013022 Issued in IL

Practice address

1159 Wilmette Ave
Suite 225
Wilmette, IL 60091-2649

Phone

(847) 728-8148

NPI assigned

Apr 19, 2017

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Arts

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Carolyn Wagner

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Wilmette, IL
  • NPI 1164047072
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1492560000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1595462400000",
    "number": "1467986141",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "116 ELMORE ST",
            "city": "PARK RIDGE",
            "state": "IL",
            "postal_code": "600683520",
            "telephone_number": "847-728-8148"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1159 WILMETTE AVE",
            "address_2": "SUITE 225",
            "city": "WILMETTE",
            "state": "IL",
            "postal_code": "600912649",
            "telephone_number": "847-728-8148"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "CAROLYN",
        "credential": "MA, LPC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-04-19",
        "last_updated": "2020-07-23",
        "certification_date": "2020-07-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "178.008548",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180.013022",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Amy Claire Wagner, PH.D., L.M.F.T.
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• Miroslaw Jan Walo, MD
• Mary M Walther, LCSW

• Professional Counselor in Wilmette, IL
• Providers in Wilmette, IL by specialty
• Professional Counselor in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.