| NPI | 1790294726 |
|---|---|
| Former Name | KELLYN WAGNER |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: C.1700505) |
| Additional Taxonomies | 104100000X Social Worker (Licence: C.1700505) |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2022-07-21 |