Provider Demographics
NPI:1174978183
Name:WAGERS, REBECCA A (CDCA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:WAGERS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PARK AVE W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1648
Mailing Address - Country:US
Mailing Address - Phone:419-522-5015
Mailing Address - Fax:419-522-5017
Practice Address - Street 1:28 PARK AVENUE WEST
Practice Address - Street 2:SUITE 300
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902
Practice Address - Country:US
Practice Address - Phone:419-522-5015
Practice Address - Fax:419-522-5017
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140925172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH140925OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD