Provider Demographics
NPI:1285902387
Name:WAGNER, LORI (PSYD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DANBURY ROAD
Mailing Address - Street 2:LOWER LEVEL, SUITE D6
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-0687
Mailing Address - Country:US
Mailing Address - Phone:203-494-8468
Mailing Address - Fax:845-582-0764
Practice Address - Street 1:109 DANBURY ROAD
Practice Address - Street 2:LOWER LEVEL, SUITE D6
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877
Practice Address - Country:US
Practice Address - Phone:203-494-8468
Practice Address - Fax:845-582-0764
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2706103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist