Provider Demographics
NPI:1386986677
Name:WAGNER, WILLIAM
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 APOLLO DR
Mailing Address - Street 2:SUITE 441
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4783
Mailing Address - Country:US
Mailing Address - Phone:410-318-9215
Mailing Address - Fax:240-764-6741
Practice Address - Street 1:9701 APOLLO DR
Practice Address - Street 2:SUITE 441
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4783
Practice Address - Country:US
Practice Address - Phone:410-318-9215
Practice Address - Fax:240-764-6741
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4481101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC4481OtherMD LICENSE LC4481