Lisa Fae Wagner

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

40867 Issued in CA

Practice address

29532 Bertrand Dr
Agoura Hills, CA 91301-4100

Phone

(310) 480-1719

NPI assigned

Feb 10, 2021

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

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1612915200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612915200000",
    "number": "1659963502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "29532 BERTRAND DR",
            "city": "AGOURA HILLS",
            "state": "CA",
            "postal_code": "913014100",
            "telephone_number": "310-480-1719"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29532 BERTRAND DR",
            "city": "AGOURA HILLS",
            "state": "CA",
            "postal_code": "913014100",
            "telephone_number": "310-480-1719"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "LISA",
        "middle_name": "FAE",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-02-10",
        "last_updated": "2021-02-10",
        "certification_date": "2021-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Mental Health",
            "state": "CA",
            "license": "40867",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Awakentherapycenter.com",
            "affiliation": "N",
            "endpointDescription": "A Psychological practice",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "HIE",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "21243 Ventura Blvd Ste 118",
            "city": "Woodland Hills",
            "state": "CA",
            "country_code": "US",
            "postal_code": "913642162",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Mental Health Counselor in Agoura Hills, CA
• Providers in Agoura Hills, CA by specialty
• Mental Health Counselor in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2021; 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.