Provider Demographics
NPI:1588719066
Name:WAGNER, JOHN J (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 KNIGHTSBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-2629
Mailing Address - Country:US
Mailing Address - Phone:513-388-0254
Mailing Address - Fax:513-388-0254
Practice Address - Street 1:7374 READING RD STE 110
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-3409
Practice Address - Country:US
Practice Address - Phone:937-620-0542
Practice Address - Fax:513-299-0537
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist