Provider Demographics
NPI:1366919771
Name:WAGNER, VICTORIA MCKENZIE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MCKENZIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35671 RIDGELAND DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-0874
Mailing Address - Country:US
Mailing Address - Phone:225-938-0705
Mailing Address - Fax:
Practice Address - Street 1:316 MID VALLEY CTR # 186
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-8516
Practice Address - Country:US
Practice Address - Phone:800-991-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator