Amy Claire Wagner, PH.D., L.M.F.T.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

071003893 Issued in IL

Practice address

104 Central Park Ave
Wilmette, IL 60091-3202

Phone

(847) 721-0965

NPI assigned

Jan 23, 2007

Last updated

Aug 7, 2020By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 16, 2019 through Oct 16, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

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.

• Lifecycle Therapy, PLLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Chicago, IL
  • NPI 1447950472
  NPD Authorized official

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

{
    "created_epoch": "1169510400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1596758400000",
    "number": "1568516698",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "104 CENTRAL PARK AVE",
            "city": "WILMETTE",
            "state": "IL",
            "postal_code": "600913202",
            "telephone_number": "847-721-0965"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 CENTRAL PARK AVE",
            "city": "WILMETTE",
            "state": "IL",
            "postal_code": "600913202",
            "telephone_number": "847-721-0965"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "AMY",
        "middle_name": "CLAIRE",
        "name_prefix": "Dr.",
        "credential": "PH.D., L.M.F.T.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-01-23",
        "last_updated": "2020-08-07",
        "certification_date": "2020-08-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071003893",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kannan Vinaitheerthan, LCSW
• Viridian Medical Group, PLLC
• Vital Balance Psychiatry PLLC
• Emily Vo
• Patricia Viviana Voloschin-Weiner, LCPC
• Carolyn Wagner, MA, LPC
• Marisa Wakely
• Walgreen Co (Walgreens #01033)
• Walgreen Co (Walgreens #15211)
• Miroslaw Jan Walo, MD

• Clinical Psychologist in Wilmette, IL
• Providers in Wilmette, IL by specialty
• Clinical Psychologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.