Provider Demographics
NPI:1306094255
Name:WAGNER, KARI L (PSYD)
Entity type:Individual
Prefix:DR
First Name:KARI
Middle Name:L
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 1:1615 AUGUSTA RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5629
Mailing Address - Country:US
Mailing Address - Phone:803-791-1511
Mailing Address - Fax:803-791-1572
Practice Address - Street 1:1615 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5629
Practice Address - Country:US
Practice Address - Phone:803-791-1511
Practice Address - Fax:803-791-1572
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical