Provider Demographics
NPI:1366612418
Name:WAGNER, RICHARD ELLIOTT (LPC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ELLIOTT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20395 FARM ROAD 79
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:TX
Mailing Address - Zip Code:75486-3652
Mailing Address - Country:US
Mailing Address - Phone:214-538-3200
Mailing Address - Fax:214-265-1916
Practice Address - Street 1:5470 GLEN LAKES DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4320
Practice Address - Country:US
Practice Address - Phone:214-538-3200
Practice Address - Fax:214-265-1916
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional