Corey Wagner

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

25-CRM-4021 Issued in OR

Practice address

1817 NE 6TH Ave
Portland, OR 97212-3960

Phone

(503) 719-7985

NPI assigned

Jan 16, 2025

Sex

Male

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

Medicare enrollment (NPD)

Not enrolled

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 and National Provider Directory roles.

• Oregon Change Clinic, LLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Portland, OR
  • NPI 1881293215
  NPD

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

{
    "created_epoch": "1736985600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1736985600000",
    "number": "1861203036",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1817 NE 6TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972123960"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1817 NE 6TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972123960",
            "telephone_number": "503-719-7985"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "COREY",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2025-01-16",
        "last_updated": "2025-01-16",
        "certification_date": "2025-01-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "OR",
            "license": "25-CRM-4021",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Amy W Wagner, PH.D.
• Audrey Wagner
• August Bruce Wagner
• Benjamin Wagner, MD
• Cindy Wagner
• David Wagner, PHD
• Emily Hazel Wagner
• Fiona Grace Wagner, L.M.T
• Fredrick Charles Wagner, MD
• Jeffrey David Wagner, DNP, ARNP

• Addiction (Substance Use Disorder) Counselor in Portland, OR
• Providers in Portland, OR by specialty
• Addiction (Substance Use Disorder) Counselor in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2025; 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.