Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 20040240A | IN |
Y | 103T00000X | Psychologist | 20040240A | IN |
N | 103G00000X | Clinical Psychologist | 20040240A | IN |
N | 103TC0700X | Clinical Psychologist | 20040240A | IN |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 20040240A | IN |
N | 103TS0200X | School Psychologist | 1008597 | IN |
NPI | 1134538382 |
---|---|
Provider Name | Dr. Steve Wagner |
First Address | Cincinnati, OH 45263-5283 |
Second Address | Greendale, IN 47025-8424 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2014 |
Last Update Date | 06/03/2020 |