Provider Demographics
NPI:1386734440
Name:WAGNER, LYNNE I (PHD)
Entity type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:I
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1960 N LINCOLN PARK W
Mailing Address - Street 2:UNIT 1310
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5487
Mailing Address - Country:US
Mailing Address - Phone:312-695-6946
Mailing Address - Fax:312-695-4307
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-6946
Practice Address - Fax:312-695-4307
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical